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ON 


Concussion  of  the  Spine 


NERVOUS    SHOCK 


AND  OTHER  OBSCURE  INJURIES  OF  THE  NERVOUS  SYSTEM,  IN 
THEIR  CLINICAL  AND  MEDICO-LEGAL  ASPECTS 

BY 

JOHN  ERIC  ERICHSEN,  F.R.S. 

SURGKON   EXTRAORDINARY  TO   THE   QUEEN  ;   EMERITUS   PROFESSOR   OF   CLINICAL 
SURGERY    IN    UNIVERSITY    COLLEGE,    AND    CONSULTING    SURGEON    TO 
THE   HOSPITAL  \   EX-PRESIDENT   OF  THE    ROYAL   COLLEGE    OF 
SURGEONS   OF   ENGLAND,    AND    OF  THE    ROYAL    MEDI- 
CAL   AND    CHIRURGICAL   SOCIETY,    ETC. 


•  Je  raconte,  je  ne  juge  pas  " — Montaigne. 


A  NEW  AND  REVISED  EDITION. 


NEW  YORK : 
BERMINGHAM  h  CO.,  UNION  SQUARE. 

1882. 


39-46855 


W.  L.  Mershon  &  Co., 

Printers,  Electrotypers  and  Binders^ 
Rahway,  N.  J. 


NOTICE. 

The  publication  of  a  new  edition  has  given  me  the 
opportunity  of  carefully  revising  this  work  and  of 
making  a  few  additions  to  the  text,  which,  however, 
has  been  left  substantially  unchanged. 


January  ^  1882. 


J.  E.  E. 


PREFACE. 


In  1866  I  published  Six  Lectures  on  certain  obscure 
injuries  of  the  nervous  system  commonly  met  with  as 
the  result  of  shocks  to  the  body  received  in  collisions 
on  railways.  My  objects  in  that  publication  were  to 
direct  the  attention  of  surgeons  to  a  class  of  injuries 
that  had  hitherto  been  but  little  noted ;  to  endeavor 
to  throw  some  light  on  their  true  characters;  and, 
lastly,  to  show  that  though  they  commonly  arose  from 
railway  collisions,  they  were  not  peculiar  to  them,  but 
might  be  the  consequence  of  any  of  the  more  ordinary 
accidents  of  civil  life. 

These  Lectures  attracted  some  attention  at  the 
time.  They  were  translated  into  German  by  Dr.  Kelp, 
of  Halle,  were  republished  in  America,  and  have  long 
been  out  of  print  In  this  country. 

In  the  present  work  will  be  found  some  of  the 
results  of  my  more  recent  and  extended  experience. 
In  it  the  six  original  Lectures  have  been  incorporated 
— not,  however,  without  much  alteration — and  eight 
new  Lectures  have  been  added. 

3 


*4  PREFACE. 

The  scope  of  the  work  has  been  materially  extended, 
and  the  title  has  been  changed,  so  as  to  embrace  the 
wider  range  of  subjects  of  which  it  now  treats.  These 
have  been  considered  rather  from  a  purely  clinical,  than 
from  a  physiological  or  pathological,  point  of  view. 
Throughout  these  Lectures,  but  more  especially  in  those 
on  Diagnosis  and  Prognosis,  attention  has  been  directed 
to  the  medico-legal  aspects  of  this  large,  obscure,  and 
important  class  of  injuries  of  the  nervous  system. 

To  Mr.  John  Tweedy  I  am  deeply  indebted  for  much 
valuable  assistance  in  carrying  this  volume  through  the 
press,  and  in  relieving  me  to  a  great  extent  of  those 
editorial  duties  which  press  somewhat  heavily  on  one 
otherwise  much  engaged. 


John  Eric  Erichsen. 


Cavendish  Place,  London, 
July,  1875. 


CONTENTS. 


LECTURE  I. 

INTRODUCTORY    REMARKS. 

Importance  of  Subject — Accidents  of  Civil  Life — Railway  Accidents 
— Their  Peculiarity — Importance  of  Study  of  Slight  Injuries  oi 
Spine — Brown-S6quard's  Views  on  Heredity  of  Disease  after  In- 
jury of  Nerves — Nervous  Shock  Dependent  on  Vibratory  Jar — 
Hence  frequency  in  Railway  Collisions — Opinions  of  Older  Sur- 
geons— Of  Military  Surgeons — Importance  of  Study  of  Opinions 
of  others — Dr.  Maty's  Account  of  the  Case  of  Count  de  Lordat — 
Conclusions  from  this  Case  .         .         .         .         .         .         .         .15 

LECTURE  II. 

ON  THE  EFFECTS  OF  DIRECT  AND  SEVERE  BLOWS  ON  THE  SPINE. 

Arrangements  to  be  adopted — Nature  of  Concussion  of  the  Spine — 
Four  distinct  Pathological  conditions  have  been  included  under 
this  term  :  i.  Jar  or  Shake  of  the  Cord  without  obvious  Lesion. 
2.  Compression  of  the  Cord  by  Extravasated  Blood.  3.  Compres- 
sion by  Inflammatory  Exudation.  4.  Secondary  Structural 
Changes  in  the  Cord — Diseases  of  Spinal  Column  produced  by 
direct  Violence — Opinions  and  Experiences  of  the  earlier  Surgical 
Writers — Illustrative  Cases  . 26 

LECTURE  IIL 

ON   THE    SYMPTOMS   OF    SEVERE   CONCUSSION    OF    SPINE   FROM 
DIRECT   VIOLENCE. 

Cases  of  Sudden  Death  from  Displacement  of  Fractured  Spine — 
Varieties  of  Paralysis — Primary  Effects  of  severe  direct  Injury  of 
Spine  :  (i)  Diminution  or  Loss  of  Motor  Power.  (2)  Rigidity 
and  Spasm  of  Muscles.  (3)  Diminution  or  Loss  of  Sensation. 
(4)  Perversion  of  Sensation.  (5)  Paralysis  of  Sphincters.  (6) 
Modification  of  the  Temperature  of  the  Limbs — Remote  Effects 
of  Concussion  usually  Inflammatory — Termination  of  Concussion: 
(i)  Complete  Recovery.  (2)  Incomplete  Recovery.  (3)  Perman- 
ent changes  in  the  Cord  and   its  Membranes.     (4)  Death — Fatal 


6  CONTENTS. 

Lesions  in  Spinal  Concussion:  (i)  Haemorrhage  into  Canal,  (2) 
Laceration  of  Membranes.  (3)  Extravasation  into  Substance  of 
Cord.  (4)  Disintegration  and  Inflammatory  Softening  of  the 
Cord ,         .     52 

,  LECTURE  IV. 

'  ON  CONCUSSION  OF  THE  SPINE   FROM   SLIGHT  OR  INDIRECT 

INJURY. 

Often  Symptoms  do  not  Show  themselves  for  many  Days  or  Weeks — 
Railway  Injuries  Differ  only  in  Degree  from  Ordinary  Injuries — 
Experience  of  Older  Surgeons  of  the  Effects  of  Slight  Injuries — 
Illustrative  Cases  .,...,...     78 

LECTURE  V. 

ON  CONCUSSION   OF   SPINE   FROM   GENERAL   SHOCK. 

The  Immediate  Lesion  probably  of  a  Molecular  Character — The 
Secondary  Effects  Inflammatory,  perhaps  Creeping  up  to  the 
Brain — Illustrative  Cases — Varieties  of  Injury — Mechanism  of 
Railway  Accidents — Effects  of  Position — Those  suffer  most  who 
sit  with  their  back  towards  the  Collision 93 

LECTURE  VL 

ON  SPRAINS,    TWISTS,    AND   WRENCHES   OF  THE   SPINE. 

Frequency — Symptoms,  Immediate  and  Remote — Liability  of  Spine 
to  Sprains — Illustrative  Cases — Mode  of  Occurrence  of  Sprains-r- 
Situations — Implication  of  Cord — Loosening  of  Ligaments — Prog- 
nosis— Complications  of  Strains — Illustrative  Cases — Paralysis  and 
Paraplegia  after  Twists  of  Spine — Illustrative  Cases     .         .         .115 

LECTURE  VII. 

ON  THE  MODE  OF  OCCURRENCE  OF   SHOCK,    AND   ON  THE 
PATHOLOGY   OF   CONCUSSION   OF   THE    SPINE. 

PART  J. 

ON  THE  MODE  OF  OCCURRENCE  OF  SHOCK. 

Often  a  great  Disproportion  between  the  Apparent  Injury  and  the 
Real  Damage — Slight  Accidents  sometimes  followed  by  very 
Serious  Effects — Symptoms  of  Spinal  Concussion  less  frequent 
when  other  portions  of  the  Body  have  been  seriously  injured,  unless 
Spine  has  also  been  injured — Nature  of  Primary  Changes  in  the 
Cord    Unknown — Secondary    Changes    usually    Inflammatory— 


CONTENTS.  7 

Patient  rarely  at  first  suspects  the  gravity  of  his  condition,  but 
sooner  or  later  becomes  greatly  altered — Period  of  Onset  of 
Secondary  Symptoms  varies  from  a  few  hours  to  many  months — All 
the  possible  Symptoms  of  Concussion  seldom  present  in  any  given 
case,  but  there  may  be  changes  in  Countenance,  Memory,  Intellec- 
tual Capacity,  Business  Aptitude,  Temper,  Sleep,  Sight,  Hearing, 
Taste,  Smell,  Touch,  Speech,  Attitude — Spine  is  painful  and 
unduly  sensitive — The  Gait  peculiar — Motor  Power  and  Sensation 
Impaired — Condition  of  the  Limbs  variable — State  of  Muscles 
altered — Weight  of  Body  changes — Genito-urinary  Organs — State 
of  Pulse — Order  of  Symptoms — Period  of  Supervention — Never 
perfect  Health  in  the  interval  between  the  Accident  and  manifes- 
tation of  Symptoms 141 

PART  II. 

ON   THE   PATHOLOGY   OF   CONCUSSION   OF  THE   SPINE. 

The  Symptons  of  Concussion  not  always  due  to  obvious  changes  in 
the  Cord,  but  sometimes  due  to  Molecular  alterations  or  to  Anaemia 
of  the  Cord — Two  distinctive  Pathological  States  in  Spinal  Con- 
cussion— Anaemia  and  Inflammation — Scantiness  of  Anatomical 
Knowledge  of  Morbid  Changes  in  the  Spine — Mr.  Gore's  case — 
Morbid  Anatomy  of  Spinal  Meningitis  and  of  Myelitis — Myelitis 
and  Meningitis  usually  co-existent — Symptoms  of  Concussion — 
Cerebral  Meningitis  often  present  in  Concussion  of  Spine — Spinal 
Symptoms — Effects  of  Pressure — Symptoms  referable  to  the  Limbs 
— Cord-like  Sensation  round  the  Body  .         ,         .        .         .154 

LECTURE  VIII. 

ON   SPINAL  ANEMIA,    HYSTERIA,    SHOCK  AND   UNCONSCIOUSNESS 
AS   CONSEQUENCES    OF   CONCUSSION   OF   THE    SPINE. 

Anaemia  of  Spinal  Cord,  long  known  by  the  term  of  Spinal  Irrita- 
bility— May  manifest  itself  by  pains  with  more  or  less  Paralysis 
— Symptoms,  immediate  and  remote,  most  common  in  weak  or 
overworked  young  adults,  especially  females — Spmptoms-  -Spinal 
Anaemia  a  Clinical  Inference — Pathology — Hysteria  as  a  result  of 
Spinal  Concussion — Varieties  of  Nervous  Shock — Mental  or  Moral 
or  Physical  Emotional  Symptoms  after  Accidents — Circumstances 
tending  to  induce  Hysteria — Diagnosis  of  Hysteria  after  Accidents 
— Prognosis — Unconsciousness  after  Concussion,  immediate  and 
remote 1^7 


8  CONTENTS. 

LECTURE  IX. 

ON  THE  COMPLICATIONS  OF  CONCUSSION  OF  THE  SPINE,  AND  ON 
THE  INFLUENCE  OF  INJURY  OF  PERIPHERAL  NERVES  ON  THE 
CENTRAL   PORTIONS   OF   THE    NERVOUS   SYSTEM. 

Sacrodynia:  Symptoms,  Diagnosis — Nerve  Complications — Seventh 
Nerve — Fifth  Pair — Syphilis:  Illustrative  Case — Cardiac  Debility 
— Vomiting:  Illustrative  Case — Hiccough — Intestinal  Complica- 
tions: Illustrative  Cases — Urinary  Organs — Retention  of  Urine — 
Haematuria — Diabetes — Phlebitis — Embolism  and  Thrombosis — 
Pregnancy — Influence  of  Injuries  of  Peripheral  Nerves  on  Nerve 
Centres — Illustrative  Cases 182 

LECTURE  X. 

ON   IMPAIRMENT    OF   VISION   COMPLICATING   INJURIES   OP 
THE   NERVOUS   SYSTEM. 

Vision  Impaired  by  Direct  Injury  to  the  Eye,  or  in  a  Reflex  Manner; 
(i)  Concussion  of  the  Eyeball,  (2)  Loss  of  Sight  after  Blows  on 
the  Face  from  Injury  of  Fifth  Pair  of  Nerves  —  Pathology  — 
(3)  From  Spinal  Injury — Varieties  of  Impairment — Asthenopia — 
Amblyopia — Failure  of  Power  of  Accommodation — Optic  Neuritis 
— Cilio-spinal  Region  of  the  Cord,  Section  of — Cerebral  Basic 
Meningitis.  (4)  Impairment  of  Vision  from  Injury  to  Sympathetic 
Nerve — Distribution  of  the  Sympathetic  in  the  Neck — Effects  of 
Section  of  the  Cervical  Sympathetic — Pathogenesis  of  Optic  Neur- 
itis       ............  206 

LECTURE  XL 

ON  CERTAIN  FORMS  OF  PARALYSIS  OF  THE  LIMBS  FROM  LOCAL 
INJURIES  WHICH  MAY  COMPLICATE  CONCUSSION  OF  THE 
SPINE. 

Injury  to  Supra=scapular  Nerve — Circumflex  Nerve — Musculo-spiral 
Nerve — Symptoms — Illustrative  Cases — Injury  to  Posterior  Inter- 
osseous Nerves — Symptoms — Illustrative  Case     ....  229 

LECTURE  XII. 

ON  THE  MEDICO-LEGAL  ASPECTS  OF  CONCUSSION  OF  THE  SPINE 
AND  SHOCK  OF  THE  NERVOUS  SYSTEM,  AND  ON  THEIR 
DIAGNOSIS. 

Difficulties  of  Subject — The  Estimation  of  Compensation  not  the 
duty  of  the  Medical  Man — The  Injuries  only  one  item  for  Com- 
pensation— Difficulty  of  ascertaining  exact  Nature  of  the  Injuries 


CONTENTS.  9 

— Behavior  of  Railway  Surgeons — The  Relations  of  the  Solicitor 
in  the  case — The  Report — Desirability  of  a  Conjoint  Report — 
Determination  of  Nature  and  Extent  of  Injury — Study  and  Prac- 
tice necessary — Difference  between  Signs  and  Symptoms — Value 
of  Signs — Frequency  of  Exaggeration  and  even  of  Imposture — 
Concealment  of  previous  Disease — Feigned  Symptoms,  Incon- 
stancy of — Difference  between  Weakness  and  Paralysis  of  a 
Limb — Diagnosis  of  Myelitis,  Meningitis,  and  Spinal  Anaemia — 
Diagnosis  of  Spinal  Concussion  from  (i)  Secondary  Consequences 
of  Cerebral  Commotion,  (2)  Rheumatism,  (3)  Hysteria,  (4), 
Injury  to  Nerve  Trunks,  (5)  Typhoid  Fever  ....  240 

LECTURE  XIII. 

ON   PROGNOSIS    IN   CONCUSSION  OF   THE  SPINE   IN   ITS 
CLINICAL   AND   MEDICO-LEGAL   ASPECTS. 

Prognosis  as  to  Life  in  Cervical,  Dorsal,  and  Lumbar  Regions — 
Unfavorable  in  Meningo-Myelitis — Prognosis  as  to  Recovery — 
Meaning  of  the  term  "Recovery" — Complete  Recovery — Partial 
Recovery — Time  as  an  element  in  Prognosis — Unfavorableness  of 
Progressive  Deterioration — Progressive  Amelioration  Favorable — 
Duration  of  Symptoms — Conflicting  Opinions — Causes — Impossi- 
bility of  Unanimity — Differences  of  Opinion  in  other  Professions 
-Faults  of  Medical  Witnesses — Rules  of  Medical  Evidence         .  261 

LECTURE  XIV. 

ON  THE  TREATMENT   OF  CONCUSSION   OF   THE    SPINE. 

Primary  and  Subsequent  Treatment — Importance  of  Rest  und 
Sleep — Advantages  of  Prone  Position — Exercise — Local  Applica- 
tions— Medicines — Employment  of  Mercury — Treatment  of  Spinal 
Anaemia — Electricity 284 


TABLE  OF  CASES. 


CASE  PACK 

Case  of  Count  de  Lordat .22 

1.  Fall  on  Back — Partial  Paraplegia — Recovery    .         .         .  .29 

2.  Fall  on  Back — Partial  Paraplegia — Cerebro-Meningeal  Symp- 

toms— Incomplete  Recovery  .         ,         .         .         .         .31 

3.  Blow  on  Spine  and  Head — Slow  supervention  of  Paralysis — 

Fits — Death  by  Falling  into  River        .....     34 

4.  Blow  on  Head  and  Back — Complete  Anaesthesia   of    Lower 

Limbs — Painless  Amputation         ......     36 

5.  Direct  Blow  on  Cervical  Spine — Paralysis  of  Left  Arm     .         .     39 
C.    Concussion  of  Cord  from  a  Fall   out  of    Bathing-machine — 

Paraplegia — Recovery  ........     39 

7.  Fall  from  Horseback — Concussion  of  Spine — Immediate  Earal- 

ysis — Recovery      .........     42 

8.  Compression  and  Concussion  of  Cervical  Spine  from  Blow  on 

Head — Paraplegia — Slow  Recovery  .         .         .         .44 

9.  Direct  Blow  on  Back  by  Fall — Slow  Development  of  Paralysis     45 

10.  Direct  Blow  on  Back  by  Fall  downstairs — Slow  Development 

of  Spinal  Meningitis  and  of  Paralysis 46 

11.  Concussion  of  Spine  from  direct  Violence — Condition  of  Patient 

Sixteen  Years  after  Accident  ......     47 

12.  Railway  Collision — Slowly  developed  Spinal  Meningitis  from 

Direct  Injury — Death  after  many  Months      .         .         .         .48 

13.  Severe   Contusion — Paraplegia — Laceration    of    Intervertebral 

Ligaments,  unsuspected  during  Life — Death  on  Ninth  Day    .     50 

14.  Severe  Contusion — Slight  Paralysis — Dislocation,   unsuspected 

during  Life,  between  the  Second  and  Third  Cervical  Verte- 
brae— Death  on  Fourth  Day  .         .         ....     53 

15.  Unsuspected  Fracture  of  Cervical  Spine — Slight  Paralysis — Dis- 

placement of  Spinous  Process  of  Fifth  Cervical  Vertebrae — 
Death 56 

16.  Injury  of  Spine    in    lower    Dorsal    Region — Recovery    with 

angular  Curvature         ........     63 

17.  Fall  on  Back  in   Hunting — Slow   Development  of  Paralytic 

Symptoms     .,...,....     78 


12  TABLE   OF   CASES. 

CASE  PAGB 

1 8.  Railway   Shock — Chronic  Meningitis   of   Spine   and    Head — 

Imperfect  Recovery  at  end  of  Nine  years      .         .         .         .81 

19.  Railway   Shock — Injury  to    Nervous  System — No   Immediate 

Effects — Chronic  Meningitis — Imperfect  Recovery         .         .     85 

20.  Carriage  Accident — Slow  Supervention  of  Paralytic  Symptoms  .     89 

21.  Injury  of  Spine  in  Infancy — Persistence  of  Symptoms  to  Adult 

Age 90 

22.  Concussion  of  Spine  in  Hunting — No  Direct  Injury  of  Back — 

Symptoms   of    Meningeal  Extravasation — Paraplegia — Phle- 
bitis— Pleuro-Pneumonia — Recovery      .         .         .         .         '93 

23.  Fall    in   Hunting — No  direct  Blow  on   Head  or   Spine — Slow 

Development  of  Symptoms    .......     95 

24.  Fall  in  Hunting; — Slow  Development  of  Symptoms  after  slight 

Blow  on  Head       .........     96 

25.  Carriage  Accident — No  direct  Injury  of  Head  or  Spine — Slow 

Development  of  Symptoms — Palsy  and  Anaesthesia  on  one 
Side — Hypersesthesia  on  the  other — Gradual  Recovery  .     97 

26.  Concussion  of  Spine  by  Fall  on  Feet — Gradual  Supervention  of 

Paralysis — Death  .......     98 

27.  Railway    Shock — Concussion     of     Cord — Partial     Paralysis — 

Recovery       .         .         .         .         .         .         .         .         .         .   loi 

28.  Railway  Shock — Spinal  Concussion  and  Meningitis — Slow  and 

Imperfect  Recovery       .         .         .         .         .  .         .         .    102 

29.  Railway   Shock — Concussion   of    Spine — Severe    Symptoms — 

Chronic  Meningitis — Slow  and  Imperfect  Recovery       .         .   105 

30.  Railway  Concussion — Slow  Development  of  Symptoms — Par- 

tial Paralysis — Incomplete  Recovery      .         .         .         ,         .   108 

31.  Railway  Concussion — Injury  to  Cervical  Spine — Meningitis — 

Paralysis  and  Irritation  of  Spinal  Accessory,  Circumflex,  and 
Musculo-spiral  Nerves  .         .         .         .         .         .         .110 

32.  Crush  of  Spinal  Column  by  Forcible  Bending  Forwards — No 

Paralysis  or  Injury  of  Cord   .         .         .         .         .         .  .115 

33.  Wrench  of  Spine  in  Hunting — Gradual  Development  of  Angular 

Curvature — Paraplegia — Partial  Recovery — Second  Accident 

— Abscesses  and  Death  .  •         .         .         .         .         .   irg 

34.  Railway  Collision — Severe  Strain  of  Cervical  Spine — Paralysis 

of  Left  Arm — Long-continued  Weakness  of  Neck  .         .    121 

35.  Fall   on    Head  from   Horseback^Twist  of  Cervical    Spine — 

Gradual  Paralysis  of  whole  Body — Recovery  .         .         .   124 

36.  Sudden  Twist  of  Spine — Paraplegia  .         .         .         .         .   129 

37.  Railway  Collision — Twist  of  Spine — Symptoms  not  Immediate 

— Paraplegia — Phlebitis— Recovery        .         .         .         .         .130 

38.  Severe  Wrench  of  Cervical  Spine— Paralysis — Recovery     .         .    132 


TABLE  OF  CASES.  1 3 

CASE  PAGE 

39.  Wrench  of  Spine — Relief — Relapse — Incurable  Meningo-Mye- 

litis 136 

40.  Strain  of  Back — Slowly  Progressive  Spinal  Symptoms — Grad- 

ual Development  of  Cerebral  Symptoms         .         .         .         .139 

41.  Strain  of  Back  in  Wrestling — Slowly  Progressive  Symptoms  of 

Spinal  Anaemia     .........    140 

42.  Strain  of  Lumbar  Spine  after  previous  Injury — Persistence  of 

Symptoms     ...         .......   140 

43.  Fall  in  Gymnasium — Blow   on   Back — Slow  Development  of 

Constitutional  Symptoms — Were  Symptoms  due  to  Injury  or 
to  Syphilis? 188 

44.  Blow  on    Cervical  Spine — Long- continued  "Vomiting — Partial 

Paralysis — Incomplete  Recovery 189 

45.  Fall  on  Floor — Nervous  Shock — Laceration  of  Mucous  Mem- 

brane of  Rectum — Colitis — Epithelial  Desquamation     .         .   192 

46.  Fall  on  Ice — Hsematuria  and  Haemorrhage  from  Bowels — Par- 

tial Paralysis  and  Contraction  of  Flexors  of  Feet   .         .         .   196 

47.  Railway  Shock — Difference  in  Pulse  at  Wrists — Thoracic  and 

Abdominal  Complications     .......   197 

48.  Railway   Shock — Persistent    Vomiting — Paralysis    of     Face — 

Paraplegia  Slowly  Developed — Spinal  Meningitis  .         .   198 

49.  Blow  on  Cervical  Spine — Suppression    and  Retention  of  Urine 

as  Complications  of  Spinal  Concussion  ....   199 

50.  Crush  of  Finger — Tetanic  Spasms — Progressive  Disease  of  Ner- 

vous System — Death      ........  203 

51.  Fracture  of  Shaft  of  Humerus — Paralysis  of  Trunk  of  Musculo- 

spiral  Nerve  and  Muscles  supplied  by  it        .         .         .         .  233 

52.  Wrist-drop  following  Compound  Fracture  of  the  External  Con- 

dyle of  the  Humerus — Paralysis  confined  to  the  Muscles  sup- 
plied by  the  Posterior  Interosseous  Nerve      ....  236 

53.  Wrist- drop  following  Fracture  of  Lower  Epiphysis  of  Humerus 

—Paralysis  of  Posterior  Interosseous  Nerve — Tonic  Contrac- 
tion Flexors  .........  238 

Cases  of  Imposture 251 


ON 

CONCUSSION   OF  THE  SPINE 

AND 

NERVOUS   SHOCK. 


LECTURE  I. 
INTRODUCTORY  REMARKS. 

Gentlemen. — It  is  well  known  to  every  surgeon  of 
experience  that  no  injury  of  the  head  is  too  trifling  to 
be  despised.  This  observation,  made  of  old  by  Hippo- 
crates, may  be  applied  with  equal  if  not  with  greater 
justice  to  injuries  of  the  spine.  For  if  the  brain  is  lia- 
ble to  suffer  serious  primary  lesion  and  protracted  sec- 
ondary disease  from  the  infliction  of  slight  and  per- 
haps, at  the  time,  apparently  trivial  injuries  to  the 
head,  the  spinal  cord  is  at  least  equally  prone  to  be- 
come functionally  disturbed  and  organically  diseased 
from  injuries  sustained  by  the  vertebral  column. 

My  object  in  these  Lectures  will  be  to  direct  your 
attention  to  certain  Injuries  of  the  Spine  that  may  arise 
from  accidents  that  are  often  apparently  slight,  from 
shocks  to  the  body  generally,  as  well  as  from  blows  in- 
flicted directly  upon  the  back  ;  and  to  describe  the  train 
of  progressive  symptoms  that  lead  up  to  the  obscure, 
protracted,  and  often  dangerous  diseases  of  the  spinal 
cord  and  its  membranes,  that  sooner  or  later  are  liable 
to  supervene  thereon. 

These  iniuries  of  the  spine  and  of  the  spinal  cord 
occur  not  unfrequently  in  the  ordinary  accidents  of 
civil  life — in  falls,  blows,  horse  and  carriage  accidents, 
injuries  in  gymnasiums,  &c.,  but  in  none  more  fre- 
quently or  with  greater  severity  than  in  those  which 

15 


l6  ON   CONCUSSION   OF  THE   SPINE. 

are  sustained  by  persons  who  have  been  subjected  to 
the  violent  shock  of  a  railway  collision.  And  if  in  these 
Lectures  I  speak  more  of  the  injuries  of  the  spine  aris- 
ing from  this  than  any  other  class  of  accidents,  it  is  not 
because  I  wish  to  make  a  distinction  in  injuries  of  the 
spine  according  to  their  causes,  and  still  less  to  estab- 
lish anything  like  a  speciality  of  "  railway  surgery,"  but 
rather  because  injuries  of  the  nervous  system  of  the 
kind  we  are  about  to  discuss  have  become  of  much 
practical  importance  from  the  great  frequency  of  their 
occurrence,  consequent  on  the  extension  of  railway 
trafific,  and  because  they  are  so  frequently  the  cause  of 
litigation.  There  is  also  a  special  and  painful  interest 
attaching  to  them  from  the  distressing  character  of  the 
symptoms  presented  by  the  sufferers.  Moreover,  in 
these  cases  there  is  always  a  peculiar  difficulty,  which 
is  often  greatly  increased  by  the  absence  of  evidence  of 
outward  and  direct  physical  injury,  by  the  obscurity 
and  insidious  character  of  the  early  symptoms,  the  slow- 
ly progressive  development  of  the  secondary  organic 
lesions,  and  the  functional  derangements  entailed  by 
them,  and  by  the  very  uncertain  nature  of  the  ultimate 
issues  of  the  case.  Thus  they  constitute  a  class  of  in- 
juries that  often  tax  the  diagnostic  skill  of  the  surgeon  to 
the  very  utmost.  In  his  endeavors  to  unravel  the  com- 
plicated series  of  phenomena  that  they  present,  and  in 
the  necessity  that  frequently  arises  of  separating  those 
symptoms  which  are  real  from  those  which  are  merely 
the  consequences  of  the  exaggerated  importance  that 
the  patient  attaches  to  his  injuries,  the  surgeon  will  be 
called  upon  to  exercise  much  practical  skill  and  judg- 
ment. 

Every  circumstance  connected  with  the  more  serious 
injuries  of  the  nervous  system,  whether  affecting  the 
brain,  spinal  cord,  or  peripheral  nerves — whether  aris- 
ing from  wounds,  from  fracture  of  the  skull,  or  fracture 
and  dislocation  of  the  spine — have  been  so  thoroughly 
studied  by  all  practical  surgeons  that  little  now  remains 
to  be  said  on  these  subjects,  and  with  them  I  have  at 
present  no  concern.  But  the  primary  effects  and  the 
secondary  results  of  slight  injuries  to  the  nervous  sys- 


INTRODUCTORY    REMARKS.  1 7 

tern  do  not  appear,  as  yet,  to  have  received  that  amount 
of  study  and  attention  on  the  part  of  surgeons  that 
their  frequency  and  their  importance  aHke  demand. 
The  neglect  with  which  these  cases  have  hitherto  been 
treated  appears  the  more  extraordinary  when  we  con- 
sider the  pecuHar  interest  that  their  phenomena  always 
present,  and  the  important  position  that  they  have,  of 
late  years,  assumed  in  medico-legal  practice.  There  is 
indeed  no  class  of  cases  in  which  medical  men  are  now 
so  frequently  called  upon  to  give  evidence  in  courts  of 
law,  as  those  which  involve  the  many  intricate  questions 
that  arise  in  actions  for  damages  against  railway  com- 
panies for  injuries  of  the  nervous  system,  alleged  to 
have  been  sustained  by  passengers  in  collisions ;  and 
there  is  no  class  of  cases  in  which  more  discrepancy  of 
surgical  opinion  may  be  elicited. 

It  is  partly  with  the  view  of  supplying  a  missing 
chapter  in  medical  jurisprudence  which,  as  generally 
taught  in  the  schools,  does  not  deal  sufficiently  with 
surgical  questions,  and  partly  with  the  view  and  in  the 
hope  of  clearing  up  some  of  the  more  obscure  points 
connected  with  these  injuries,  that  I  bring  this  impor- 
tant subject  before  your  notice.  I  believe  that,  as  these 
cases  come  to  be  more  carefully  studied,  and  conse- 
quently better  understood,  much  of  the  obscurity  that 
has  hitherto  surrounded  them  will  be  removed,  and  we 
shall  less  frequently  see  those  deplorable  contests  of 
professional  opinion  which  we  have  been  so  often 
obliged  to  witness  in  our  courts  of  law. 

The  importance  of  these  inquiries  has  latterly  assum- 
ed a  new  aspect  from  the  very  interesting  fact  pointed 
out  by  Brown-Sequard,"  that  in  many  animals  morbid 
states  of  various  kinds  may  be  hereditarily  transmitted 
as  the  results  of  injuries  inflicted  on  the  nervous  system 
of  one  or  other  of  their  parents.  Thus,  for  instance, 
this  distinguished  physiologist  has  experimentally 
proved  that  epilepsy  may  appear  by  transmission,  in 
animals  whose  parents  have  been  rendered  epileptic  by 
an  injury  of  the  spinal  cord,  t  as  well  as  in  the  offspring 

*  Lancet,  vol,  i.  p.  7,  1875. 
f  Proceedings  of  Royal  Society,  Jan.  i86g. 
2 


1 8  ON   CONCUSSION   OF   THE   SPINE. 

of  those  in  which  that  disease  has  been  induced  by  sec- 
tion of  the  sciatic  nerve.  Exophthalmia,  malformations 
of  the  ears  and  toes,  partial  closure  of  the  eyelids, 
haematoma,  and  dry  gangrene  of  the  ears,  have  all  been 
thus  produced  in  animals ;  and  although  there  is  no 
proof  as  yet  that  analogous  effects  can  be  developed  in 
man  by  heredity  from  parents  who  have  suffered  an  in- 
jury of  the  nervous  system,  yet  we  may  fairly  assume 
that  such  is  the  case ;  and  now  that  attention  has  been 
called  to  this  important  subject,  we  may  expect  to  find 
similar  instances  in  the  human  being. 

I  purpose  illustrating  these  Lectures  by  cases  drawn 
from  my  own  practice,  and  by  a  reference  to  a  few  of 
the  more  interesting  published  cases  that  bear  upon 
the  subject.  In  doing  so,  I  shall  confine  myself  to  the 
details  of  a  few  selected  instances.  It  would  be  as  use- 
less as  it  would  be  tedious  to  unduly  multiply  the 
illustrations,  as  they  all  present  analogous  trains  of 
symptoms  and  phenomena.  I  wish  particularly  and 
very  specially  to  impress  upon  you,  that  although  I  shall 
have  frequent  occasion  to  speak  of  "  shocks  "  to  the 
nervous  system  arising  from  railway  accidents,  I  do  not 
consider  that  these  injuries  stand  in  a  different  category 
from  accidents  occurring  from  other  causes  in  civil  life; 
and  it  will  be  one  of  the  main  objects  of  these  Lectures 
to  show  you  that  precisely  the  same  effects  may  result 
from  other  and  more  ordinary  injuries.  It  must, 
however,  be  evident  to  you  all,  that  in  no  ordinary 
accidents  can  the  shock,  physical  and  mental,  be  so 
great  as  those  that  occur  on  railways.  The  rapidity  of 
the  movement,  the  momentum  of  the  persons  injured 
and  of  the  vehicle  that  carries  them,  the  suddenness  of 
its  arrest,  the  helplessness  of  the  sufferers,  and  the 
natural  perturbation  of  mind  that  must  disturb  the 
bravest,  are  all  circumstances  which  necessarily  greatly 
increase  the  severity  of  the  resulting  injury  to  the 
nervous  system,  and  which  have  led  surgeons  to  con- 
sider these  cases  as  somewhat  exceptional  and  different 
from  ordinary  accidents.  There  is,  in  fact,  much  the 
same  difference  between  these  and  the  more  ordinary 
injuries  of  the  nervous  system  as  there  is  between  a 


INTRODUCTuRY    REMARKS.  I9 

gunshot  wound  and  other  contused  and  lacerated 
wounds  of  the  Hmbs.  The  cause  is  special,  and  the 
results  are  peculiar  ;  but  though  peculiar  they  are  not  so 
unlike  those  arising  from  other  accidents  as  to  justify 
us  in  regarding  them  as  being  in  any  essential  respect 
distinct  and  different.  The  peculiarity  of  these  obscure 
injuries  of  the  nervous  system  caused  by  railway 
shocks  is  sufficiently  great,  however,  to  warrant  us  in 
grouping  them  together,  and  considering  them  as  a 
whole  in  a  separate  chapter  in  the  great  book  of  Sur- 
gery. 

Perhaps  the  one  circumstance  which  more  than  any 
other  gives  a  peculiar  character  to  a  railway  accident 
is  the  thrill  or  jar,  the  *'  ebranlement "  of  French  writ- 
ers, the  sharp  vibration,  in  fact,  that  is  transmitted 
through  everything  subjected  to  it.  It  is  this  vibra- 
tory shock  or  jar  which  by  some  is  compared  to  an 
electric  shock,  by  others  to  setting  the  teeth  on  edge, 
that  causes  a  carriage  to  be  shattered  into  splinters, 
and  occasions  the  sharp  tremulous  movement  that  runs 
through  every  fibre  of  its  occupants  and  that  consti- 
tutes the  shock.  In  addition  to  all  this  the  body  of 
the  traveler  is  thrown  to  and  fro,  often  five  or  six 
times,  without  any  power  of  resistance  or  self-preserva- 
tion. 

But  although  the  intense  shock  to  the  system  that 
results  from  these  accidents  naturally  and  necessarily 
gives  to  them  a  terrible  interest  and  importance,  do  not 
for  a  moment  suppose  that  these  injuries  are  peculiar 
to  or  solely  occasioned  by  accidents  that  occur  on  rail- 
ways. 

There  never  was  a  greater  error.  It  is  one  of  those 
singular  mistakes  that  has  arisen  from  men  trusting 
too  much  to  their  own  individual  experience,  and  pay- 
ing too  little  heed  to  the  observations  of  their  prede- 
cessors. It  is  an  error  begot  in  egotism  and  nurtured 
by  indolence  and  self-complacency.  It  is  easy  for  a 
man  to  say  that  such  and  such  a  thing  cannot  exist, 
because  "  I,  in  my  large  experience  at  our  hospital, 
never  saw  it,"  whereas,  if  he  would  take  the  trouble, 
he  would  find,  by  the  study  of  their  works,  that  sur- 


20  ON  CONCUSSION  OF  THE   SPINE. 

geons  of  equally  large,  or  perhaps  of  far  greater,  expe- 
rience in  their  generation  have  seen  and  described  it. 

Formerly  this  opinion  might  have  been  excusable ; 
it  is  no  longer  so.  The  comparative  rarity  of  these 
obscure  injuries  of  the  nervous  system  in  ordinary  hos- 
pital practice  and  in  private,  caused  them  either  to  be 
entirely  overlooked,  or  to  be  regarded  as  mere  surgical 
curiosities.  Now,  however,  since  they  occur,  unfortu- 
nately, too  frequently  in  groups,  sometimes  of  scores 
at  a  time,  they  have  been  brought  under  the  observa- 
tion of  every  surgeon,  and  their  symptoms,  prognosis, 
diagnosis  and  treatment  form  an  important  part  of  the 
professional  occupation  of  practitioners  in  every  part 
of  the  country,  who  may  at  any  time  be  called  upon  to 
diagnose  and  treat  such  cases,  or  to  give  evidence  con- 
cerning them. 

If  we  look  into  the  surgical  literature  of  the  past 
century  we  shall  find  that  cases  of  slight  accidents  to 
the  spine  or  head,  followed  by  serious  persistent  or 
fatal  results,  were  not  unknown;  but  they  were  of  such 
rare  occurrence  that  surgeons  of  the  greatest  experi- 
ence do  not  appear  to  have  seen  a  sufficiently  large 
number  to  treat  specially  of  them. 

Sir  Astley  Cooper,  who  certainly  enjoyed  a  wider 
range  of  experience  in  surgical  practice  than  has  ever 
before  or  since  fallen  to  the  lot  of  any  one  man  in  this 
country,  said  that  his  experience,  extensive  as  it  had 
been,  was  only  as  a  bucket  of  water  out  of  the  great 
ocean  of  surgical  knowledge. 

In  the  writings  of  Sir  A.  Cooper  himself,  in  those  of 
his  predecessors  and  contemporaries,  especially  or 
Boyer,  of  Sir  C.  Bell,  and,  at  a  later  period,  of  Ollivier 
and  Abercrombie,  you  will  find  many  isolated  cases 
recorded  which  prove  incontestably  that  precisely  the 
same  series  of  phenomena  that  of  late  years  have  led 
to  the  absurb  appellation  of  the  "  Railway  Spine,"  had 
followed  accidents,  and  had  been  described  by  sur- 
geons of  the  first  rank  in  this  country  and  in  France,  a 
quarter  of  a  century  and  more  before  the  first  railway 
was  opened,  and  that  they  were  then  generally  recog- 
nized as  arising  from  the  common  accidents  of  civil 


INTRODUCTORY   REMARKS.  21 

life.  The  only  difference  is,  that  accidents  have 
greatly  increased  in  frequency  and  intensity  since  the 
introduction  of  railways,  and  these  injuries  have  be- 
come proportionally  more  numerous  and  more  severe. 

I  have  hitherto  spoken  only  of  these  injuries  as  oc- 
curring in  the  ordinary  accidents  of  civil  life  and  on 
the  railways,  but  they  are  not  unknown  to  the  Army 
Surgeons.  In  the  "Army  Medical  Report,"  issued  by 
the  United  States  Government,  on  the  Surgery  of  the 
Great  War  of  the  Rebellion,  there  are  seventy-five 
cases  reported  under  the  head  of ''  Contusions  and  Mis- 
cellaneous Injuries  of  the  Spine,"  from  which  all  cases 
of  fracture  and  of  dislocation  are  excluded.  From 
this  report  the  following  facts  may  be  gleaned.  Of  the 
seventy-five,  two  died  from  causes  unconnected  v/ith 
the  accident,  twenty-seven  were  discharged  from  the 
service  as  unfit  for  duty,  and  three  returned  to  easy 
duty,  the  remaining  forty-three  returned  to  military 
duty.  No  mention  is  made  of  the  duration  of  the 
treatment  in  thirty-two  of  the  cases.  Of  the  remainder 
it  is  stated  as  follows:  one,  fourteen  months ;  one, 
twelve  months ;  and  one,  six  months ;  three,  five 
months ;  two,  three  months ;  one,  two  months ;  and 
two,  under  one  month. 

The  causes  of  the  injuries  are  stated  as  follows  in 
thirty-eight  cases : — 


Falls  from  horses 
Simple  falls  . 
Struck  by  branches'  , 
Blows  from  muskets 
Railway  accident 


14 . .  died  I . .  recovered  6 .  .  discharged  7 

15      "      I  "  6  "8 

4      "     o  "  4  "  o 

3      "      o  "  I  "2 

2       "       o  "  I  "I 


Bacon  has  truly  said,  "  They  be  the  best  physicians 
which,  being  learned,  incline  to  the  traditions  of  expe- 
rience, or,  being  empirics,  incline  to  the  methods  of 
learning."  The  same  remark  is  applicable  to  surgeons, 
and  that  observation  is  as  true  at  the  present  day  as 
Avhen  it  was  made,  nearly  three  hundred  years  ago. 

Yes,  truly,  gentlemen,  if  you  are  "  empirics,"  incline 
to  the  methods  of  learning.  Do  not  trust  wholly  to 
your  own ''  empiricism;"  in  other  words,to  your  own  indi- 
vidual experience;  but  learn  what  has  been  seen  by  others 


21  ON   CONCUSSION   OF  THE   SPINE. 

of  equal,  perhaps  of  greater,  experience  than  yourselves  ; 
as  accurate  in  observing,  and  as  truthful  in  recording. 
The  study  of  the  works  of  such  men  is  not  a  vain  and 
futile  learning,  but  one  replete  with  valuable  results.  In 
reading  their  works,  you  feel  that  you  come  into  direct 
communion  with  these  great  men, — with  the  Boyers, 
the  Bells,  and  the  Coopers, — and  from  them  you  will 
learn  many  a  lesson  of  practical  wisdom,  the  direct  re- 
sult of  their  accurate  observations. 

But  you  may  go  further  back  than  the  writings  of 
these  great  men,  and  you  will  find  scattered  here  and 
there  throughout  medical  literature  some  most  interest- 
ing cases  that  bear  upon  this  very  point.  You  will  find 
much  in  this  literature  that  anticipates  what  are  often 
erroneously  supposed  to  be  more  recent  discoveries. 
Many  a  man  imagining  that  he  has  struck  out  a  new 
vein  of  truth,  has  found  that  years  ago  it  had  been 
explored  and  the,  ore  extracted  by  his  predecessors, 
and  has  had  to  exclaim,  ''  Per e ant  ante  nos  qui  nostra 
dixereT 

If  you  take  up  the  third  volume  of  the  "  Medical 
Observations  and  Inquiries,"  you  will  find  that  in  1766, 
more  than  one  hundred  years  ago,  a  case  is  related  by 
Dr.  Maty  of  "  a  Palsy  occasioned  by  a  fall,  attended 
with  uncommon  symptoms,"  which  is  of  so  interesting 
a  nature,  and  which  bears  so  closely  upon  our  subject, 
that  I  feel  that  I  need  offer  no  apology  for  giving  you 
an  abstract  of  it  here,  although  as  it  occurred  between 
sixty  and  seventy  years  before  the  first  railway  was 
opened  in  this  country,  it  might  at  first  appear  to  have 
less  relation  to  railway  accidents  than  it  really  has,  for 
in  its  course  and  symptoms  it  is  identical  with  many  of 
them. 

This  case,  which  is  given  at  length,  and  which  I  shall 
abstract  from  the  original,  is  briefly  as  follows : 

Count  de  Lordat,  a  French  officer  of  great  rank  and 
much  merit,  whilst  on  his  way  to  join  his  regiment,  in 
April,  1 761,  had  the  misfortune  to  be  overturned  in  his 
carriage  from  a  pretty  high  and  steep  bank.  His  head 
pitched  against  the  top  of  the  coach  ;  his  neck  was 
twisted  from  right  to  left ;  his  left  shoulder,  arm,  and 


INTRODUCTORY   REMARKS.  23 

hand  were  much  bruised.  As  he  felt  at  the  time  Httle 
inconvenience  from  the  fall,  he  was  able  to  walk  to  the 
next  town,  which  was  at  a  considerable  distance. 
Thence  he  pursued  his  journey,  and  it  was  not  till  the 
sixth  day  that  he  was  let  blood  on  account  of  the  injury 
to  the  shoulder  and  hand. 

The  Count  went  through  the  fatigues  of  the  cam- 
paign, which  was  a  very  trying  one.  Towards  the  begin- 
ning of  the  winter  (at  least  six  months  after  the  acci- 
dent), he  began  to  find  an  impediment  to  the  utterance 
of  certain  words,  and  his  left  arm  appeared  to  be 
weaker.  He  underwent  some  treatment,  but  without 
much  advantage  ;  made  a  second  campaign,  at  the  end 
of  which  he  found  the  difficulty  in  speaking  and  in 
moving  his  left  arm  considerably  increased.  He  was 
now  obliged  to  leave  the  army  and  return  to  Paris,  the 
palsy  of  the  left  arm  increasing  more  and  more.  Many 
remedies  were  employed  without  effect.  Involuntary 
convulsive  movements  took  place  all  over  the  body. 
The  left  arm  withered  more  and  more,  and  the  Count 
could  hardly  utter  a  few  words. 

This  was  in  December,  1763,  two  years  and  a-half 
after  the  accident. 

He  consulted  various  physicians,  and  underwent 
much  treatment  without  benefit. 

In  October,  1764,  three  years  and  a-half  after  the  fall, 
Dr.  Maty  saw  him.  "A  more  melancholy  object,"  he 
says,  ''  I  never  beheld.  The  patient,  naturally  a  hand- 
some, middle-sized,  sanguine  man,  of  a  cheerful  dis- 
position and  an  active  mind,  appeared  much  ema- 
ciated, stooping,  and  dejected.  He  walked  with  a  cane, 
but  with  much  difficulty,  and  in  a  tottering  manner." 
His  left  hand  and  arm  were  wasted  and  paralyzed  ;  his 
right  was  somewhat  benumbed,  and  he  could  scarcely 
lift  it  up  to  his  head.  His  saliva  dribbled  away  ;  he 
could  only  utter  monosyllables,  "  and  these  came  out, 
after  much  struggling,  in  a  violent  expiration,  and  with 
a  low  tone,  and  indistinct  articulation."  Digestion  was 
weak,  urine  natural.  His  senses  and  the  powers  of  his 
mind  were  unimpaired.  He  occupied  himself  much  in 
reading  and  writing  on   abstruse   subjects.     No   local 


24  ON   CONCUSSION   OF  THE   SPINE. 

tumor  or  disease  was  discoverable  in  the  neck  or  any- 
where else.  From  this  time  his  health  gradually- 
declined,  and  he  finally  died  on  the  5th  March,  1765, 
nearly  four  years  after  the  accident. 

On  examination  after  death,  the  pia  mater  of  the 
brain  was  found  ^'  full  of  blood  and  lymph ;"  and  to- 
wards the  falx  there  were  some  marks  of  suppuration. 
The  medulla  oblongata  is  stated  to  have  been  greatly 
enlarged,  being  about  one-third  larger  than  the  natural 
size.  The  membranes  of  the  cord  were  greatly  thick- 
ened and  very  tough.  The  cervical  portion  of  the 
cord  was  hardened,  so  as  to  resist  the  pressure  of  the 
fingers. 

"  From  these  appearances,"  says  Dr.  Maty,  "  we  were 
at  no  loss  to  fix  the  cause  of  the  general  palsy  in  the 
alterations  of  the  medulla  spinalis  and  oblongata."  The 
twisting  of  the  neck  in  the  fall  had  caused  the  mem- 
branes of  the  cord  to  be  excessively  stretched  and  irri- 
tated ;  the  morbid  changes  then  extended  by  degrees 
to  the  spinal  marrow,  which,  being  thereby  compressed, 
brought  on  the  paralytic  symptoms. 

This  case  is  of  the  utmost  interest  and  importance ; 
and  though  it  occurred  and  was  published  more  than  a 
century  back,  it  presents  in  so  marked  a  manner  the 
ordinary  features  of  "  Concussion  of  the  Spine,"  that  it 
may  almost  be  considered  a  typical  case  of  one  of  those 
accidents. 

The  points  to  which  I  would  particularly  beg  to 
direct  your  attention  in  this  case  are  these : 

1st.  That  there  was  no  evidence  of  blow  upon  the 
spine, — merely  a  twist  of  the  neck  in  the  fall. 

2d.  That  no  immediate  inconvenience  was  felt,  ex- 
cept from  the  bruise  on  the  shoulder  and  hand. 

3d.  That  the  patient  was  able  to  walk  a  considerable 
distance,  and  to  continue  his  journey  after  the  occur- 
rence of  the  accident. 

4th.  The  symptoms  of  paralysis  did  not  manifest 
themselves  for  several  months  after  the  injury. 

5th.  They  were  at  first  confined  to  the  left  arm  and 
to  the  parts  of  speech. 

6th.  They  very  slowly  but   progressively  increased, 


INTRODUCTORY   REMARKS.  2$ 

extending   to  the   left   leg   and    slightly  to  the    right 
arm. 

7th.  This  extension  of  paralysis  was  very  gradual, 
occupying  two  or  three  years.  The  sphincters  were 
not  affected,  and  the  urine  was  healthy. 

8th.  The  general  health  gradually  but  slowly  gave 
way,  and  death  at  last  ensued,  after  a  lapse  of  four 
years,  by  a  gradual  decay  of  the  powers  of  life. 

9th.  After  death,  evidences  of  disease  were  found  in 
the  membranes  of  the  cord  and  the  cord  itself.  The 
narrator  of  the  case  stating  that  the  membranes  were 
primarily,  and  the  cord  secondarily,  affected. 

You  will  find,  as  we  proceed  in  the  investigation  of 
this  subject,  that  the  symptoms,  their  gradual  develop- 
ment, and  the  after-death  appearances  presented  by 
this  class,  are  typical  of  the  whole  class  of  Injuries  of 
the  Spine  grouped  together  under  the  one  common 
term  ''  Concussion,"  from  whatever  cause  arising. 

The  term  ''  Concussion  of  the  Spine  "  has  been 
objected  to,  and  it  has  been  proposed  to  substitute 
"  Concussion  of  the  Cord,"  on  the  ground  that  we  say, 
"  Concussion  of  the  Brain  "  and  not  of  "  the  Head." 
But  the  cases  are  not  similar.  The  spine,  irrespective 
of  its  cord,  is  a  much  more  complicated  structure  than 
the  head.  In  "  Concussion  of  the  Spine,"  we  have  not 
only,  and  not  even  necessarily,  an  injury  of  the  cord, 
but  also,  and  perhaps  solely,  an  injury  of  the  osseous, 
fibrous,  ligamentous,  and  muscular  structures  that 
enter  so  largely  into  the  conformation  and  support  of 
the  vertebral  column — of  the  nerves  that  pass  across  it — 
and  of  the  membranes  included  within  it.  Injuries  of 
these  parts  often  occasion  very  grave  and  most  persis- 
tent symptoms  without  any  lesion  whatever  of  the  cord. 


26  ON   CONCUSSION   OF  THE   SPINE. 


LECTURE    II. 

EFFECTS    OF    DIRECT    AND    SEVERE    BLOWS    ON    THE 

SPINE. 

It  is  not  my  intention  in  these  Lectures  to  occupy 
your  time  with  any  remarks  on  those  injuries  of  the 
spine  that  are  attended  by  distinct  and  immediate  signs 
of  lesion,  such  as  fracture  or  dislocation  of  the  vertebral 
column,  or  direct  wound  of  the  cord  itself.  The  nature 
and  the  consequences,  proximate  and  remote,  of  such 
injuries  as  these  are  obvious,  and  are  so  well  under- 
stood by  all  engaged  in  surgical  practice,  that  the  con- 
sideration of  them  need  not  detain  us.  And  what  I 
have  to  say  about  them  I  have  stated  at  length  else- 
where.* 

My  present  object  is  to  call  your  attention  to  the 
effects,  local  and  constitutional,  immediate  and  remote, 
of  certain  forms  of  injury  from  which  the  spinal  cord  is 
liable  to  suffer  without  serious  lesion  of  its  protecting 
column  or  enveloping  membranes.  These  injuries,  on 
account  of  the  obscurity  of  their  primary  symptoms, 
the  gradual  development  of  their  secondary  phenomena, 
and  the  ultimate  severity  and  long  persistence  of  the 
evils  they  occasion,  are  of  the  greatest  interest  to  the 
practical  surgeon. 

In  considering  these  injuries,  I  shall  adopt  the  fol- 
lowing arrangement : — 

1.  The  effects  of  severe  blows  directly  applied  to  the 
spine,  but  without  obvious  lesion  of  bone  or  ligament. 

2.  The  consideration  of  the  effects  of  slight  and 
apparently  trivial  injuries  applied  directly  to  the  spine. 

3.  The  effects  that  injuries  of  distant  parts  of  the 
body,  or  that  shocks  of  the  system,  unattended  by  any 
direct  blow  upon  the  back,  have  upon  the   spinal   cord. 

4.  The  effects  produced  by  sprains,  wrenches,  or 
twists  of  the  spine. 

Firstly.  Let  us   inquire  into  the  effects,  immediate 

*  Science  and  Art  of  Surgery,  seventh  edition,  vol.  i,,  chaps,  xxiv.  and 

XXV. 


SEVERE   BLOWS   ON   THE   SPINE.  2/ 

and  remote,  of  those  forms  of  concussion  of  the  spinal 
cord  which  follow  a  severe  degree  of  external  violence 
applied  to  the  vertebral  column. 

It  is  by  no  means  easy  to  give  a  clear  and  compre- 
hensive definition  of  the  term,  "  Concussion  of  the 
Spine."  Without  attempting  to  do  so,  it  may  be 
stated,  that  this  phrase  is  generally  adopted  by  sur- 
geons to  indicate  a  certain  state  of  the  spinal  cord 
occasioned  by  external  violence  ;  a  state  that  is  inde- 
pendent of,  and  usually,  but  not  necessarily,  uncom- 
plicated by  any  obvious  lesion  of  the  vertebral  column, 
such  as  its  fracture  or  dislocation, — a  condition  that  is 
supposed  to  depend  upon  a  shake  or  jar  received  by 
the  cord,  in  consequence  of  which  its  intimate  organic 
structure  may  be  more  or  less  deranged,  and  by  which 
its  functions  are  certainly  greatly  disturbed,  so  that 
various  symptoms  indicative  of  loss  or  modification  of 
innervation  are  immediately  or  remotely  induced. 

The  primary  effects  of  these  concussions  or  commo- 
tions of  the  spinal  cord  are  probably  due  to  molecular 
changes  in  its  structure.  The  secondary  are  mostly  of 
an  inflammatory  character,  or  are  dependent  on  retro- 
gressive organic  changes,  such  as  softening,  etc.,  conse- 
quent on  interference  with  its  nutrition. 

It  would  appear  that  surgeons  and  writers  on  dis- 
eases of  the  nervous  system  have  included  four  distinct 
pathological  conditions  under  this  one  term,  ''  Concus- 
sion of  the  Spine,"  viz.,  i.  A  jar  or  shake  of  the  cord, 
disordering,  to  a  greater  or  less  degree,  its  functions, 
without  any  lesion  perceptible  to  the  unaided  eye.  2. 
Compression  of  the  cord  slowly  produced  by  the  extra- 
vasation of  blood.  3.  Compression  of  the  cord  by  inflam- 
matory exudations,  serum,  lymph,  or  pus  within  the 
spinal  canal ;  and,  4.  Chronic  alterations  of  the  struc- 
ture of  the  cord  itself  as  the  result  of  impairment  of 
nutrition  consequent  on  the  occurrence  of  one  or  other 
of  the  preceding  pathological  states,  but  chiefly  of  the 
third.  These  various  conditions  differ  remarkably  from 
one  another  in  their  symptoms  and  effects,  and  have 
only  this  in  common,  that  they  are  not  dependent  upon 
an  obvious  external    injury  of  the  spine,  such  as  the 


28  ON   CONCUSSION   OF  THE   SPINE. 

laceration  or  compressioii  of  the  cord  by  the  fracture  or 
dislocation  of  a  vertebra. 

Concussion  or  Commotion  of  the  Spinal  Cord 
as  a  result  of  severe  and  direct  blows  upon  the 
back  is  a  morbid  condition  that  has  long  been  rec- 
ognized and  carefully  described  by  those  v/ho  have 
written  on  the  effects  of  injury  of  this  important  part 
of  the  body. 

It  must  not  be  forgotten,  however,  that  severe  and 
direct  blows  on  the  back  may  develop  disease  in  the 
vertebral  column  and  the  meninges  in  which  the  cord 
may  become  secondarily  implicated,  and  which  may 
creep  on  by  continuity  of  structure  to  the  membranes 
of  the  brain. 

The  changes  set  up  in  the  structures  that  enter  into 
the  conformation  of  the  vertebral  column  by  direct 
blows  on  the  back  may  terminate  in  caries,  angular  cur- 
vature, abscess,  etc.  This  is  matter  of  common,  in  fact 
every-day  surgical  observation.  Cases  of  this  kind  will 
be  referred  to  in  the  course  of  these  Lectures.  It  will 
suffice  here  to  say  that  such  disease  may  be  developed 
from  the  very  earliest  infancy  to  the  adult  age  from 
such  violence.  I  have  even  known  the  slapping  of  the 
back  of  a  newly-born  infant  to  make  it  breathe  develop 
caries  of  the  dorsal  spine,  and  from  that  early  age  direct 
violence  cannot  be  applied  to  the  spine  without  immi- 
nent risk  of  inducing  local  disease. 

Sir  A.  Cooper^  relates  two  cases  of  concussion  of  the 
spine,  one  terminating  at  the  end  of  ten  weeks  in  com- 
plete, the  other  in  incomplete  recovery. 

Mayof  relates  two  cases.  In  one  at  the  end  of  six 
months  there  was  no  amelioration.  In  the  other  at  the 
end  of  four  months  symptoms  of  inflammatory  soften- 
ing of  the  cord  set  in. 

Sir  Charles  Bell  :j:  relates  two  most  interesting  cases 
of  concussion  of  the  spine,  both  occasioned  by 
falls  and  blows  on  the  back.  In  one  of  the  cases 
the  symptoms  were  immediate,  but   in  the  other  they 

*  Dislocations  and  Fractures  of  Joints,  8vo.  ed.,  p.  526  et  seq. 

J  Outlines  of  Pathology.     London,  1836. 
Surgical  Observations.     London,  1816. 


SEVERE   LLOWS   UN   THE   SPINE.  29 

developed  themselves  slowly  after  an  interval  of  some 
months. 

Boyer"^  relates  two  cases.  In  one  the  patient  struck 
his  loins  by  falling  into  a  deep  ditch.  He  was  affected 
by  complete  paraplegia,  and  speedily  died.  On  exam- 
ination no  morbid  appearances  could  be  detected, 
there  being  no  fracture,  dislocation,  effusion,  or  any 
lesion  of  the  cord  or  its  membranes.  In  the  other  case, 
a  man  amusing  himself  with  gymnastic  exercises  strain- 
ed his  back  between  the  shoulders.  He  became  para- 
plegic, and  died  in  a  few  weeks.  After  death  no  lesion 
of  any  kind  was  found  in  the  spine  or  cord. 

Abercrombie,  in  his  well-known  and  philosophical 
treatise  on  the  Brain  and  Spinal  Cord,t  has  a  short 
chapter  on  this  injury,  in  which  he  relates  several  cases 
from  his  own  observations  and  from  the  practice  of 
others,  in  which  the  characteristic  symptoms  of  con- 
cession of  the  cord  followed  blows  upon  the  spine. 

Ollivierif  has  collected,  from  his  own  practice  and 
that  of  others,  thirteen  cases  of  this  injury.  They  are 
detailed  with  much  minuteness.  Several  of  these 
proved  fatal,  and  of  these  the  after  death  appearances 
are  given  at  length. 

The  following  cases  will  illustrate  some  of  the  chief 
points  of  interest  in  the  development  of  the  symptoms 
and  progress  of  spinal  concussion  from  the  infliction  of 
severe  and  direct  injury  to  the  spine. 

Case  I.  Fall  on  Back — Partial  Paraplegia — Recovery. 
— A  man,  42  years  of  age,  a  clerk,  fell  whilst  getting 
down  from  the  roof  of  an  omnibus,  and  struck  his  back 
heavily  upon  the  ground.  He  tried  to  get  up,  but  was 
unable  to  do  so,  and  was  carried  to  University  Colege 
Hospital,  where  he  was  admitted  in  February,  1857, 
under  my  care. 

On  examination  it  was  found  that  he  had  a  trans- 
verse bruise  upon  the  back,  in  the  dorso-lumbar  region, 
probably  from  coming  in  contact  with  the  step  of  the 
vehicle  in  his  fall.     He  suffered  pain  on  pressure  about 

*  Maladies  Cliirurgicales,  vol.  iii.,  p.  135. 

f  London,  1828,  p.  375, 

\  Traite  des  Maladies  de  la  Moelle  Epiniere.      Paris,  1837. 


30  ON   CONCUSSION   OF  THE   SPINE. 

the  bruised  part ;  but  no  irregularity  in  the  line  of  the 
spinous  processes  or  any  other  sign  of  fracture  or  of 
injury  to  the  vertebrae  could  be  detected.  The  ecchy- 
mosis  extended  over  the  two  or  three  last  dorsal  and 
the  first  lumbar  vertebrae.  His  consciousness  was  in  no 
way  disturbed.  He  could  not  stand,  as  his  legs  gave 
way  under  him.  He  complained  of  complete  numbness 
in  the  left  leg,  but  in  the  right  there  was  a  certain 
degree  of  sensibility  associated  with  tingling,  pricking 
sensations.  When  laid  in  bed  he  could  not  move  the 
jeft  lower  extremity,  but  he  could  flex  the  right  thigh 
upon  the  abdomen  and  draw  up  the  knee,  though  he 
could  not  raise  the  foot.  The  catheter  was  passed  and 
clear  urine  drawn  off. 

He  was  ordered  complete  rest  in  bed ;  five  grains 
of  calomel,  to  be  followed  by  a  purgative  enema,  and 
the  use  of  the  catheter,  if  necessary,  every  eighth  hour. 

Febrile  reaction  set  in,  which  continued  for  three 
or  four  days.  He  was  quite  unable  to  empty  the 
bladder  ;  the  urine  was  consequently  drawn  off  by  the 
catheter.  There  was  no  incontinence  of  flatus  or  of 
faeces.  The  state  of  the  lower  extremities  remained 
unaltered. 

At  the  end  of  a  week  he  was  decidedly  better ;  he 
could  raise  the  right  foot  from  the  bed,  and  the  normal 
sensibility  of  that  limb  had  in  a  great  measure  returned. 
He  could  draw  up  the  left  knee,  and  there  was  some 
sensation  in  the  leg  and  in  the  dorsum  of  the  foot.  The 
retention  of  urine  continued. 

At  the  end  of  a  fortnight  motion  and  sensation  had 
returned  in  the  right  lower  extremity,  but  the  left  limb 
was  still  weak  and  partially  numb,  with  formications 
and  tinglings.  He  now  began  to  pass  his  urine — which 
was  acid — without  the  use  of  the  catheter.  During  the 
Avhole  of  this  period  the  only  treatment  that  had  been 
adopted  was  rest  in  bed,  with  an  occasional  aperient. 
He  was  now  ordered  to  sit  up,  and  had  dry  cupping  to 
the  lower  part  of  the  spine. 

At  the  expiration  of  another  week  he  was  able  to 
move  about  on  his  feet  with  a  tottering,  straddling  gait, 
by  the  aid  of  a  chair  and   stick.     He  now  steadily  im- 


SEVERE   BLOWS   ON   THE   SPINE.  3 1 

proved  both  in  appearance  and  In  power  of  moving. 
At  the  end  of  the  first  month  he  could  walk  with  but 
little  assistance  ;  he  was  still  very  weak  in  the  left  leg, 
which  was  partially  numb  ;  it  felt  as  if  asleep,  and  tin- 
gled. 

Stimulating  embrocations  were  ordered  to  the  spine, 
and  he  was  ordered  the  twelfth  of  a  grain  of  perchlo- 
ride  of  mercury  in  a  drachm  of  compound  tincture  of 
chinchona  thrice  a  day.  Under  this  treatment  he 
steadily  improved,  and  was  able  to  leave  the  hospital 
at  the  end  of  the  sixth  week,  walking  with  the  aid  of  a 
stick.  He  was  treated  as  an  out-patient  with  stryxh- 
nine  and  iron,  and  the  local  application  of  galvanism, 
for  two  or  three  weeks  longer,  and  then  dismissed 
cured. 

This  case  is  related  as  an  instance  of  not  very  un- 
common occurrence,  in  which,  after  a  severe  and  direct 
blow  upon  the  spine,  paraplegic  symptoms  are  suddenly 
developed,  which  again  disappear  completely  in  the 
course  of  a  few  weeks  under  the  influence  of  rest  and 
appropriate  treatment.  The  only  point  of  special 
interest  in  this  case  is,  that  although  there  was  paralysis 
and  complete  retention,  the  urine  continued  acid 
throughout.  It  is  probable  that  the  pathological  lesion 
in  such  a  case  as  this  consists  of  some  intra-vertebral 
extravasation  of  blood,  the  compression  exercised  by 
which  occasions  the  symptoms,  which  disappear  as  the 
blood  becomes  gradually  absorbed. 

Case  2.  Fall  on  Back — Partial  Paraplegia — Cerebro- 
MeJiingeal  Symptoms — Incomplete  Recovery. — A  painter, 
30  years  of  age,  was  admitted  into  University  College 
Hospital,  under  my  care,  in  June  1865,  under  the  fol- 
lowing circumstances.  He  stated  that  whilst  painting 
a  house  he  over-reached  himself,  and  fell  with  the 
ladder  to  the  ground,  a  height  of  about  thirty  feet,  and 
struck  his  back  upon  a  gravel  walk.  His  hand  was  cut 
in  the  fall,  but  his  head  was  uninjured.  On  admission 
he  was  found  somewhat  collapsed,  cold,  and  with  a  fee- 
ble pulse.  There  was  no  evidence  of  fracture  either  of 
spine  or  pelvis,  but  the  back  was  ecchymosed  to  some 
extent  about  the  centre  of  the  dorsal  region.     He  could 


32  ON   CONCUSSION   OF   THE   SPINE. 

not  stand,  but  when  lying  in  bed  could  draw  up  the 
knees  nearly  to  a  right  angle,  although  he  was  unable 
to  raise  the  feet,  he  complained  of  numbness  and  ting- 
ling in  both  legs  and  feet,  but  could  feel  when  pinched 
or  pricked.  The  patient  had  perfect  control  over  his 
sphincters,  and  the  urine  was  acid. 

He  was  treated  by  rest  in  bed,  dry  cupping  to  the 
spine,  and  occasional  aperients.  At  the  end  of  a 
month  he  had  not  improved,  being  as  nearly  as  possi- 
ble in  the  same  state  as  on  admission.  He  was  now 
put  on  small  doses  of  the  perchloride  of  mercury  in 
bark,  and  had  counter-irritation  applied  to  the  spine. 
Some  little  amendment  took  place  under  this  plan  of 
treatment,  and  in  August  he  was  able  to  sit  up,  but 
could  neither  walk  nor  stand  without  support,  and 
continued  to  complain  of  the  numbness  and  tingling  in 
his  legs.  Towards  the  end  of  the  month  he  seemed  to 
have  acquired  slight  power  over  the  legs,  and  could 
manage,  by  dragging  them  along,  and  leaning  on  a 
chair  and  stick  or  crutch,  to  move  across  the  ward. 
He  now  very  slowly  improved,  and  by  the  end  of  Sep- 
tember was  able  to  leave  the  hospital.  He  was  emaci- 
ated, cachectic-looking,  and  could  barely  manage  to 
walk  and  drag  his  leg,  by  holding  on  to  the  furniture 
or  by  pushing  a  chair  before  him.  He  continued 
through  the  winter  mending  but  very  slowly.  Towards 
the  early  part  of  the  following  year  he  was  taken 
charge  of  by  the  Sisters  of  Mercy,  who  sent  him  to 
their  establishment  at  Clewer.  There  he  gradually  re- 
gained a  certain  degree  of  health  and  strength.  I  saw 
him  again  on  April  20,  exactly  ten  months  after  the 
accident ;  he  was  then  in  the  following  state : 

He  described  himself  as  being  languid,  depressed, 
and  as  if  going  out  of  his  mind.  His  memory  had  be- 
come very  bad — at  times  all  seemed  a  blank  to  him. 
When  he  went  on  an  errand  he  often  could  not  recol- 
lect what  it  was  about ;  was  always  obliged  to  write  it 
down.  His  thoughts  were  confused ;  he  often  mixed 
up  one  thing  with  another.  He  was  very  nervous  and 
easily  frightened.  He  dreamt  much,  and  was  told  that 
he  talked  and  cried  in  his  sleep. 


SEVERE   BLOWS   ON   THE   Sl'INE.  33 

He  said  he  was  "  not  the  same  man  that  he  was," 
and  thought  he  never  would  be.  He  could  not  do  or- 
dinary work  as  before  the  accident — only  *'  odd  jobs." 
He  could  not  walk  more  than  a  mile,  and  could  not 
carry  a  pail  of  water  without  great  exertion. 

He  was  never  free  from  an  aching,  throbbing  pain 
in  the  back ;  most  severe  in  the  middle  dorsal  region. 
There  the  spine  was  very  tender  on  pressure,  and  the 
tenderness  extended  to  some  distance  on  either  side  of 
it,  more  especially  on  the  left.  This  pain  was  greatly 
increased  by  movement  of  any  kind,  especially  by 
bending  backwards.  He  stooped  with  great  difficulty, 
and  was  obliged  to  go  upon  one  knee  in  order  to  pick 
anything  off  the  floor.  He  walked  in  a  shuffling,  un- 
steady manner,  and  always  used  a  stick.  He  com- 
plained of  numbness  and  "  pins  and  needles  "  in  the 
right  leg  and  foot.  There  was  no  difference  in  the  size 
of  the  limbs. 

He  had  suffered  since  the  accident  from  muscae  vol- 
itantes  and  colored  spectra,  ''  like  the  rainbow  "  before 
his  eyes.  Light  did  not  distress  him,  but  loud  noises 
did.     His  hearing  was  very  acute  indeed. 

No  irritability  of  bladder ;  held  and  passed  his  water 
well ;  urine  acid. 

In  December,  1867,  two  years  and  a  half  after  the 
occurrence  of  the  accident,  he  was  still  suffering  from 
very  severe  pain  at  the  lower  part  of  the  spine  and  in 
the  dorsal  region.  He  walked  with  great  difficulty  in 
a  bent  posture,  and  was  quite  unable  to  do  any  active  or 
continuous  work.  He  was  again  admitted  into  the  hos- 
pital, but  did  not  materially  improve  under  treatment. 

This  case  presents  a  good  example  of  concussion  of 
the  spine  followed  by  partial  paralysis  of  sensation  and 
motion  of  the  lower  limbs  without  affection  of  the 
sphincters  or  alkalinity  of  urine,  terminating  in  incom- 
plete recovery. 

It  appears  to  me  doubtful  whether  intra-vertebral 
haemorrhage  took  place  in  this  case  ;  but  there  can  be 
little  doubt  that  the  spinal  cord  had  sustained  some 
serious  organic  lesion  which  interfered  with  complete 
recovery 

3 


34  ON   CONCUSSION   OF   THE   SPINE. 

In  some  cases,  however,  the  result  is  not  so  satisfac- 
tory even  as  in  this ;  the  symptoms  that  are  immedi- 
ately developed  continuing  for  many  years,  even  for 
the  remainder  of  the  patient's  life,  without  change. 

Case  3.  Blozv  on  Spine  mid  Head — Slow  supervention 
of  Paralysis — Fits — Death  by  falling  into  River. — H.  N., 
aged  43,  a  carpenter  at  Bishops  Stortford,  admitted 
into  University  College  Hospital,  October  15,  1866. 
Had  been  a  hard-working  man  of  temperate  habits ; 
always  enjoyed  good  health  till  he  met  with  the  fol- 
lowing accident:  More  than  three  years  ago,  one  day 
in  June,  1863,  he  was  assisting  to  load  a  wagon  with 
woodwork,  when  just  as  it  was  about  to  be  tied  down 
with  rope,  some  of  it  slipped  and  fell  on  to  the  side  of 
the  patient,  who  was  stooping  by  the  cart.  Four 
pieces  fell,  the  first  of  which  struck  him  on  the  back  of 
the  head,  knocked  him  down  and  stunned  him.  The 
other  pieces  fell  across  his  back.  They  were  heavy 
beams,  intended  for  the  roof  of  a  church,  25  ft.  long 
and  6  in.  square.  After  the  accident  he  was  able  to 
walk  a  short  distance  home,  and  had  no  paralysis  after- 
wards. He  was,  however,  laid  up  for  four  months. 
He  was  much  bruised,  and  suffered  from  violent  pains 
in  the  back  of  his  head.  He  was  treated  with  embro- 
cations only.  At  the  end  of  four  months  he  again 
went  to  work,  though  he  had  still  some  constant  pain 
in  the  back,  with  every  now  and  then  a  severe  exacer- 
bation, so  that  he  was  obliged  to  lay  up  for  a  few  days. 
He  continued  in  this  state  until  June,  1866,  when  he 
was  suddenly  affected  with  giddiness ;  on  stooping  he 
fell  down.  His  back  also  became  worse.  His  medical 
attendant  then  cupped  and  blistered  him  energetically, 
and  at  the  end  of  seven  weeks  he  was  sufficiently  im- 
proved to  go  to  the  seaside.  He  remained  there  a 
month,  and  was  much  better  when  he  returned  to 
work,  but  soon  became  as  bad  as  before.  He  con- 
tinued doing  as  little  work  as  he  was  able,  until  Octo- 
ber, when  he  came  up  to  London.  He  did  not  suffer 
from  giddiness  until  June,  1866,  three  years  after  the 
accident.  At  the  same  time  his  sight  began  to  fail. 
If  he  read  for  a  short  time,  the  letters  began  to  dance 


SEVERE   BLOWS   ON   THE   SPINE.  35 

before  his  eyes.  He  suffered  also  from  noises  in  his 
ears  and  head,  and  from  failure  of  memory,  especially 
forgetting  what  he  had  just  been  told  or  what  had  re- 
cently happened. 

About  the  same  time  also  he  began  to  suffer  occa- 
sional paralysis  of  the  right  arm  and  hand,  lasting  from 
a  few  minutes  to  an  houn  There  was  no  pain  in  the 
arm  at  these  times,  but  complete  loss  of  both  sensation 
and  motion.  The  return  of  power  was  accompanied 
by  the  unpleasant  sensation  of  "  pins  and  needles." 
After  July,  however,  he  was  not  troubled  with  these 
attacks.  He  had  never  had  rheumatism  or  gout,  and 
and  had  had  but  little  carrying  or  lifting  of  weights  in 
his  work. 

On  admission  the  patient  was  tolerably  stout,  though 
he  said  he  had  lost  flesh  since  the  accident.  He  had  a 
somewhat  vacant  expression  of  countenance,  and  a 
hesitating  way  of  speaking.  He  was  verj'  easily  con 
fused,  especially  respecting  names  and  dates.  The 
muscles  were  well  developed,  though  rather  flabby,  and 
patient  generally  presented  slight  evidences  of  illness. 
On  applying  pressure  along  the  link  of  the  vertebral 
spines  three  tender  spots  were  met  with  in  the  lower 
cervical  (fifth  and  sixth)  middle  dorsal  and  lumbar  re- 
gions. The  last  was  the  most  painful,  the  former  less 
so.  He  complained  especially  of  a  sensation  of  cold 
water  being  poured  down  his  spine,  also  of  numbness 
down  the  back  of  his  thighs. 

Bowels  very  regular.  He  cannot  sleep  well  at  night. 
When  he  does  sleep  he  is  continually  dreaming. 

He  was  ordered  to  take  the  sixteenth  of  a  grain  of 
perchloride  of  mercury  in  an  ounce  of  decoction  of 
bark,  three  times  a  day.  Blisters  to  be  applied  to  the 
tender  spots  on  the  spine. 

25th. — Spine  has  been  repeatedly  blistered  both  with 
liq.  vesicatorius  and  emp.  lyttse,  but  patient's  skin  is 
very  obstinate,  and  but  little  result  has  been  produced. 
Condition  much  the  same. 

Nov.  2nd. — Patient  has  been  kept  in  bed,  lying  a 
good  deal  on  his  face.  His  back  has  been  well  blis- 
tered, and   he  expresses  himself  much  relieved.     The 


36  ON   CONCUSSION   OF   THE   SPINE.      , 

•tenderness  at  the  upper  part  of  the  back  has  disap^ 
peared ;  that  in  the  lumbar  region  is  not  much  altered. 
The  pains  up  the  back  and  occiput  have  also  disap- 
peared. Appetite  good,  bowels  regular,  but  patient 
sleeps  little  and  lightly. 

I2th. — Patient  much  the  same.  Rather  less  tender- 
ness in  the  lumbar  region.  Still  much  insomnia. 
Blisters  to  be  repeated. 

17th. — Patient  gets  up  daily.  No  pain  in  back  or 
head  ;  no  tenderness  on  pressure  anywhere ;  back  still 
sore  from  blisters ;  general  health  good ;  sleeps  better. 

23rd. — No  tenderness  on  pressure  at  any  part  of  the 
back.  Th :  blisters  are  all  but  healed.  Patient  looks 
much  better  than  on  admission,  and  has  lost  much  of 
his  vacant  expression.  He  has  also  less  hesitation  in  his 
speech. 

26th. — Patient  says  he  is  in  better  health  than  he  has 
been  since  the  accident.  Has  nothing  whatever  to  com- 
plain of. 

After  the  patient's  return  home  he  was  able  to  re- 
sume work  to  a  certain  evtent.  He  was,  however, 
seized  with  "  fits,"  probably  epileptiform,  and  in  one  of 
these  fell  into  the  river  and  was  drowned,  as  I  was  in- 
formed by  Dr.  Glasscock. 

This  case  is  interesting,  as  showing,  i.  The  slow 
supervention  of  paralysis  after  a  severe  concussion  of 
the  spine  from  direct  violence ;  2,  The  effect  of  treat- 
ment ;  and  3.  The  supervention  of  "  fits,"  as  the  para- 
lytic symptoms  declined. 

The  following"'^  is  one  of  the  most  remarkable  cases 
on  record,  of  long  persistent  paralysis  after  a  blow  on 
the  spine,  the  loss  of  sensation  being  so  complete  that 
the  patient  submitted  to  the  amputation  of  both  thighs 
without  feeling  the  slightest  pain.  As  this  case  has 
never,  I  believe,  been  published  in  this  country,  and  is 
of  so  very  remarkable  a  character,  I  have  thought  that 
it  might  not  be  out  of  place  to  give  an  abstract  of  it 
here. 

Case  4. — B/ozt^  on  Head  and  Back — Complete  AncEs- 

*  Eve's  Surgical  Cases,  p.  90  ;  and  New  Yoi'k  Journal  of  Medicine^ 
1853.     By  U.  D.  Purple,  M.D.,  of  Greene,  N.  Y. 


SEVERE   BLOWS   ON   THE   SPINE.  37 

tkesia  of  Loivcr  Limbs — Amputation  without  Sensation. — 
A  man,  22  years  of  age,  in  felling  a  tree,  was  struck  on 
the  back  part  of  the  head  and  between  the  shoulders 
by  a  large  bough.  This  accident  occurred  in  1845.  The 
force  of  the  blow  expended  itself  chiefly  on  the  lower 
cervical  spine  and  the  shoulders.  A  complete  paralysis 
of  sensation  and  motion,  of  all  the  parts  below  this, 
was  the  immediate  result.  This  condition  continued 
without  the  slightest  change.  The  vital  and  animal 
functions  were  naturally  performed.  Respiration,  cir- 
culation, digestion,  secretion,  and  assimilation,  were  all 
about  normal.  There  was  a  sensible  increase  in  the  fre- 
quency and  volume  of  the  circulation,  and  respiration 
was  noticed  to  be  slightly  increased  in  frequency  above 
the  normal  standard.  The  weight  of  the  body  became 
greater  after  than  it  had  been  before  the  injury,  and  the 
lower  limbs  retained  their  natural  heat  and  physical 
development. 

The  patient  evidenced  an  unusual  share  of  mental 
vigor  after  the  injury,  and  possessed  a  resolution  and 
determination  that  are  described  as  truly  surprising  in 
his  forlorn  and  helpless  condition.  He  threw  himself 
into  the  midst  of  society  for  excitement,  and  was  fond 
of  travelling,  lying  on  his  back  in  his  carriage. 

In  1 85 1,  six  years  after  the  accident,  he  presented 
himself  in  the  County  Medical  Society  (Greene,  New 
York),  aud  requested  the  amputation  of  his  lower  ex- 
tremities, which  he  stated  were  a  burdensome  appen- 
dage to  the  rest  of  his  body,  causing  him  much  labor 
in  moving  them,  and  stating  that  he  wanted  the  room 
they  occupied  in  his  carriage  for  books  and  other 
articles.  He  insisted  on  the  operation  with  his  wonted 
resolution  and  energy.  The  surgeon  whom  he  con- 
sulted at  first  refused  to  consent  to  amputation,  not 
only  objecting  to  so  extensive  a  mutilation  for  such 
reasons  as  he  gave,  but  fearing  lest  the  vitality  of  the 
vegetative  existence  enjoyed  by  his  limbs  might  be  in- 
sufficient for  a  healthy  healing  process.  The  patient, 
still  determined  in  his  resolve  to  have  the  limbs  cut  off 
as  a  useless  burden  to  the  rest  of  the  body,  sought  other 
advice,  and  at  last  had  his  wishes  gratified.  . 


38  ON  CONCUSSION  OF  THE   SPINE. 

Both  limps  were  amputated  near  the  hip-joints,  with- 
out the  sHghtest  pain  or  even  the  tremor  of  a  muscle. 
The  stumps  healed  rapidly,  and  no  unfavorable  symp- 
toms occurred  in  the  progress  of  perfect  union  by  the 
first  intention.  In  this  mutilated  state  he  was  perfectly 
unable  to  move  his  pelvis  in  the  slightest  degree.  He 
resumed  his  wandering  life,  and  travelled  over  a  great 
part  of  the  States.  He  died  in  May,  1852,  of  disease  of 
the  liver,  brough  on  by  his  excess  in  drink,  to  which  he 
had  become  greatly  addicted  since  his  accident.  No 
post-mortem  examination  was  made. 

This  case  is  a  most  remarkable  one  from  several 
points  of  view,  and  from  none  more  than  this,  that  a 
double  amputation  of  so  serious  a  character  could  be 
successfully  practiced  on  a  person  affected  by  complete 
paraplegia,  and  yet  that  the  stumps  healed  by  the  first 
intention.  Besides  this  remarkable  fact,  there  are  two 
special  points  of  interest  in  this  case  which  bear  upon 
the  subject  that  we  are  now  considering,  viz.,  that  the 
weight  of  the  body  is  stated  to  have  increased  after  the 
accident,  and  that  the  limbs  which  were  so  completely 
paralyzed  as  to  admit  of  amputation  without  the  patient 
experiencing  the  slightest  sensation  of  pain,  had  in  no 
way  wasted  during  the  six  years  that  they  had  been 
paralyzed,  but  retained  ''  their  normal  physical  develop- 
ment," as  is  expressly  stated  in  the  report  of  the  case. 
We  can  have  no  stronger  evidence  than  this  to  prove 
that  mere  disuse  of  a  limb  for  a  lengthened  period  of 
years  even,  is  not  necessarily  followed  by  the  wasting 
of  it. 

I  will  now  proceed  to  relate  a  series  of  cases  of  in- 
jury of  the  spine  from  direct  violence,  unattended  by 
signs  of  fractures  or  dislocations,  which  will  tend  to 
prove  many  facts  of  interest  in  reference  to  concussion 
of  the  cord. 

Thus  Case  5  shows  that  a  concussion  of  the  spine 
may  be  followed  by  paralysis  of  one  limb  only.  Case 
6  is  one  of  paraplegia,  with  recovery,  following  fall  on 
back.  Case  7  shows  general  paralysis  from  fall  from 
horseback,  and  concussion  of  spine.  Case  8  is  an  in- 
stance of  the  evils  resulting  from  vertical  concussion  of 


SEVERE   BLOWS   ON  THE   SPINE.  39 

the  spine.  Case  9  is  an  instance  of  the  slow  develop- 
ment of  symptoms  after  spinal  concussion.  Case  10, 
another  instance  of  the  slow  development  of  symp- 
toms. Case  1 1  illustrates  the  condition  of  a  patient 
sixteen  years  after  concussion  of  the  spine  ;  and  Cases 
12  and  13  are  instances  of  death  following  concussion 
of  the  spine. 

Case  5.  Direct  Blow  on  Cervical  Spine — Paralysis  of 
Left  Arm. — W.  C,  aged  62,  was  sent  to  me  on  April  8, 
1870,  by  Dr.  Kydd.  Whilst  felling  a  tree  last  year  he 
was  struck  by  a  heavy  branch  on  the  left  side  of  the 
neck,  shoulder,  and  spine.  There  was  no  fracture  or 
dislocation  ;  the  severity  of  the  blow  was  expended  on 
the  side  of  the  neck,  chest,  and  shoulder;  the  head 
was  not  struck.  The  whole  of  the  left  arm  in- 
stantly became  paralyzed,  both  as  to  sensation  and 
motion,  and  had  been  so  ever  since.  On  examination 
I  found  the  muscles  attached  to  the  scapula  and  the 
humerus  were  wasted  to  a  considerable  extent,  as  were 
also  those  of  the  arm  and  forearm.  The  limb  was 
rigid,  the  joints  could  not  be  flexed  without  a  very 
considerable  amount  of  pain.  The  fingers  were  partly 
flexed,  and  sensation  was  entirely  lost  below  the  elbow. 
Above  this  part  it  was  normal.  He  suffered  severe 
pain  along  the  course  of  the  ulnar  and  median  nerves, 
which  came  on  in  spasms  and  was  very  intense.  There 
was  tenderness  on  pressure  from  the  sixth  cervical  to  the 
fifth  or  sixth  dorsal  vertebra,  and  constant  pain  there. 
The  case  appeared  to  be  one  of  paralysis  of  the  nerves 
of  the  upper  extremity,  from  a  direct  blow  on  the 
spine,  about  the  region  of  the  brachial  plexus  on  the 
left  side. 

Case  6. — Concussion  of  Spinal  Cord  from  a  Fall  out 
of  Bat  king-Mac  kine — Uncomplicated  Paraplegia — Recov- 
ery.— A  young  gentleman,  aged  14,  after  bathing  at 
Weymouth  on  September  9,  1873,  slipped  off  the  steps 
of  the  machine,  and  fell  backwards  into  shallow  water, 
striking  the  sandy  bottom.  He  received  no  bruise  or 
other  mark  of  external  injury ;  was  not  stunned  or 
even  rendered  momentarily  unconscious.  But  he  felt 
as  if  he  had   sprained  his  back.     He   got   out  of  the 


40  ON  CONCUSSION  OF  THE  SPINE. 

water  unaided,  was  assisted  to  dress,  and  walked  home, 
a  distance  of  a  few  hundred  yards.  He  was  then 
obliged  to  lie  down,  as  his  legs  felt  weak  and  numb. 
The  weakness  and  numbness  gradually  increased,  so 
that  he  could  not  walk  or  even  stand.  He  was  brought 
up  to  London  in  an  invalid  carriage,  and  I  saw  him 
on  September  19,  in  consultation  with  Dr.  Playfair,  and 
Mr.  Myers  of  the  Coldstream  Guards. 

I  found  him  a  stout,  healthy,  well-grown  lad,  per- 
fectly well  to  all  appearance,  except  for  the  paraplegia. 
On  examination  we  found  that  the  left  leg  w^as  much 
more  paralyzed  than  the  right.  He  was  quite  unable 
to  stand,  even  when  supporting  himself  by  his  hands ; 
on  attempting  to  do  so,  his  knees  bent  under  him  and 
he  sank  down.  When  lying  in  bed  on  his  back,  he 
could  draw  up,  cross,  and  kick  out  his  legs,  apparently 
quite  in  a  natural  way.  But  on  closer  examination 
w^e  found  the  following  conditions : 

1.  The  right  leg  and  thigh  could  be  moved  freely. 
The  four  movements  of  the  foot  could  be  moderately 
well  but  not  powerfully  executed. 

2.  He  could  bend  and  move  the  left  thigh  and  leg, 
but  rather  feebly.  The  four  movements  of  the  foot 
were  very  imperfectly  done,  more  especially  "  perona- 
tion."  He  could  flex  and  adduct  the  foot  moderately 
well.  But  he  was  quite  incapable  of  abducting  it,  and 
when  he  attempted  to  draAv  up  the  foot  he  merely 
called  into  action  the  extensors  of  the  toes. 

3.  He  had  numbness  and  tingling  down  the  outer 
side  of  the  left  thigh  as  far  as  the  knee.  The  sensibil- 
ity below  the  knee  was  materially  diminished.  That 
of  the  right  leg  was  normal.  Extremities  were  cold, 
especially  the  left  foot. 

4.  There  was  occasional  slight  loss  of  control  over 
the  sphincters. 

5.  There  was  some  weakness  in  the  left  arm,  and  the 
grasp  of  the  hand  was  very  feeble. 

6.  The  left  leg  measured  half  an  inch  less  in  circum- 
ference at  the  calf  than  the  right  one. 

7.  The  spine  was  very  tender  at  two  parts,  viz.,  at 
the  seventh  cervical  and  at  the  third  lumbar  vertebrae. 


vSEVERE   BI.OWS   OX   THE   SPINE.  4I 

The  pain  was  greatly  increased  on  movement,  rotation, 
pressure  downwards,  but  especially  on  bending  back- 
wards. 

The  treatment  prescribed  was  absolute  rest  on  a  sur- 
gical couch,  and  the  twenty-fourth  of  a  grain  of  the 
perchloride  of  mercury,  with  bark  twice  a  day. 

Sept.  30th. — Has  continued  without  any  material 
change  up  to  the  present  time.  To-day  complains  of 
extreme  and  diffused  tenderness  about  the  lower  cer- 
vical and  upper  dorsal  spines.  He  shrinks  when  lightly 
touched,  and  starts  away  from  the  finger.  This  ten- 
derness is  diffused  over  the  whole  breadth  of  the  back, 
nearly  to  the  lateral  median  lines,  and  occupies  a  space 
in  length  equal  to  that  from  the  fourth  or  fifth  cervical 
to  the  sixth  dorsal  vertebrae.  There  is  also  tenderness 
to  the  left  of  the  lumbar  spine.  He  was  now  seen  by 
Drs.  Priestley  and  Farquharson,  as  well  as  by  Mr. 
Myers  and  myself.  We  ordered  three  grains  of  iodide 
of  potassium  in  bark,  with  ammonia,  three  time  a  day ; 
belladonna  liniment  to  the  back,  and  absolute  rest. 

Oct.  7th. — Is  much  better.  Diffused  tenderness  of 
back  is  less.  The  pain  on  pressure  and  movement  of 
the  spine  the  same.  Still  quite  unable  to  stand.  Per- 
onation  of  the  left  foot  is,  however,  better  performed. 

Nov.  4th. — He  has  slowly  improved  during  the  past 
month.  Has  taken  the  iodide  of  potassium  and  bark 
regularly,  and  been  blistered  on  the  nape  of  the  neck 
and  upper  dorsal  region.  To-day  he  was  able  to  stand, 
and,  with  assistance,  to  walk  across  the  room.  The 
movements  of  the  left  foot  were  nearly  normal,  and  on 
measurement  it  was  found  by  Dr.  Farquharson  and 
myself  that  the  left  leg  had  regained  its  natural  size. 
From  this  time  the  patient  steadily  improved.  He  was 
sent  to  the  seaside,  and  in  about  four  months  had  com- 
pletely regained  his  health  and  strength,  and  the  full 
use  of  the  left  lower  extremity. 

This  case  was  probably  one  of  concussion  of  the 
spine,  attended  by  slight  intra-spinal  haemorrhage — 
the  gradual  supervention  of  the  symptoms,  and  their 
slow  subsidence,  pointing  to  this  as  the  pathological 
state.     It  is   interesting  to  observe  in  connection  with 


42  ON   CONCUSSION   OF  THE   SPINE 

the  nutrition  functions  of  the  nerves,  that  the  left  leg 
had  decreased  half-an-inch  in  circumference  in  a  fort- 
night, and  that  as  the  paralytic  symptoms  disappeared 
it  regained  its  normal  girth,  although  it  had  not  been 
exercised  by  any  movement — a  clear  proof  that  it  was 
lesion  of  the  nerves  and  not  disuse  that  influenced  its 
nutrition. 

Case  7.  Fall  from  Horseback — Concussion  of  Spine — 
Lnmediate  Paralysis  —  Complete  Recovery.  —  Lt.-Col. 
S. ,  aged  44,  whilst  riding  at  the  head  of  his  bat- 
talion on  Sept.  4,  1872,  near  Poonah,  was  thrown  from 
his  horse  on  to  a  hard  road,  alighting  on  his  head,  with- 
out being  able  to  break  the  fall  with  his  hands.  The 
helmet  he  wore  saved  his  skull,  but  through  the  violence 
of  the  concussion  with  the  ground,  he  was  thrown 
heavily  on  the  flat  of  his  back,  in  which  position  he  lay 
completely  paralysed  as  regards  motion.  He  never  lost 
consciousness,  nor  was  in  any  way  stunned.  He  was 
immediately  seen  by  Dr.  Meadows,  who  found  him  to 
be  completely  paralysed  as  to  motion  but  not  as  to  sen- 
sation. There  was  no  fracture  or  other  injury  of  any 
bone.  Staff-Surgeon  Giraud,  under  whose  care  he  sub- 
sequently came,  states  that  for  the  first  two  or  three 
days  after  the  accident  his  bladder  did  not  act,  the 
catheter  had  to  be  used,  and  for  some  three  or  four 
weeds  he  lost  flesh  and  weight  rapidly ;  but  from  that 
time  he  continued  slowly  but  gradually  to  improve. 
When  first  seen  by  Dr.  Giraud,  on  December  20,  the 
following  was  his  condition  : — Incomplete  paralysis"  of 
itiotion  and  of  sensation  of  both  upper  and  lower  ex- 
tremities, most  pronounced  in  the  left  arm  and  right 
leg ;  numbness  and  blunted  sensibility  of  the  whole  of 
the  surface  of  the  body  below  the  neck,  more  especially 
in  the  particular  limbs  just  mentioned,  and  on  the  right 
side  of  the  body.  His  mental  condition  was  unim- 
paired, his  spirits  good.  The  respiratory  and  abdo- 
minal movements  unimpeded,  appetite  good  ;  he  had 
regained  power  over  his  bladder,  but  his  urine  was  alka- 
line ;  the  bowels  were  constipated,  and  there  was  a  loss 
of  control  over  the  sphincter  ani.  He  had  much  diffi- 
culty in   getting   from   the   recumbent   to   the  upright 


SEVERE   BLOWS   ON  THE   SPINE.  43 

position,  and  when  on  his  legs  could  just  balance  him- 
self, feeling  that  the  least  touch  would  knock  him  over  ; 
he  could  walk  only  a  few  yards  with  difficulty,  his  gait 
being  awkward  and  uncertain  ;  there  were  no  external 
marks  of  injury  either  on  the  spine  or  head.  On  March 
6,  1873,  six  months  after  the  accident,  his  convalescence 
is  stated  to  have  been  slow  and  gradual,  but  uninter- 
rupted. The  symptoms  just  described  still  remained, 
though  in  a  much  less  marked  degree.  He  could  stand 
up  and  walk  about  half  a  mile  with  confidence  ;  he  had 
increased  in  weight  and  put  on  flesh  ;  his  bowels  were 
more  regular  and  more  under  control ;  his  appearance 
was  good,  and  his  general  health  and  spirits  excellent, 
and  as  his  progress  towards  recovery  had  then  been 
going  on  slowly  and  uninterruptedly  for  several  months, 
there  was  every  reason  to  hope  he  would  ultimately 
recover.  The  treatment  that  was  adopted  in  India 
consisted  of  rest,  plain  and  nourishing  diet,  a  liberal 
allowance  of  claret  or  burgundy,  plenty  of  fresh  air,  and 
shampooing.  Strychnine  and  moderate  doses  of  qui- 
nine and  iron  were  administered,  and  the  bowels  regu- 
lated by  suitable  aperients.     I  saw  Col.  S. on  his 

arrival  in  England  on  the  26th  March.  He  had  im- 
proved greatly  during  the  voyage,  being  considerably 
better  in  all  respects  than  when  he  left  India.  There 
was  no  cerebral  disturbance,  no  impairment  of  any  of 
the  senses.  He  ate  and  slept  well  ;  he  had  complete 
control  over  the  sphincter  of  the  bladder,  but  had  not 
regained  power  over  the  sphincter  aiii.  The  paralysis 
chiefly  affected  the  left  arm  and  right  leg  :  he  dragged 
this  leg  very  remarkably.  There  was  a  good  deal  of 
rigidity  in  both  of  these  limbs,  more  especially  about 
the  shoulder,  and  pain  on  flexing  or  moving  them  ex- 
tensively. The  paralysis  in  the  arm  chiefly  affected  the 
muscles  supplied  by  the  musculo-spiral  and  the  circum- 
flex nerves.  There  was  numbness  in  both  the  lower 
extremities,  but  the  right  leg  and  thigh  were  less  sensi- 
tive than  the  left.  He  complained  of  numbness  in  both 
hands.  The  spine  was  tender  on  pressure  and  painful 
on  movement  in  the  upper  dorsal  region.  The  grasp 
of  the  hands  was  weakened,  the  pressure  on  the  dyna- 


44  ON   CONCUSSION   OF   THE   SPINE. 

mometer  of  the  right  hand  indicating  27  lbs.,  that  of 
the  left  only  15  lbs.  There  was  very  marked  hyperaes- 
thesia  of  the  right  hand,  and,  more  or  less,  of  the  sur- 
face of  the  body  generally.  If  he  put  the  hand  into 
cold  water  it  felt  as  if  it  were  being  scalded.  He  could 
not,  for  the  same  reason,  bear  a  cold  bath,  as  the  skin 
on  the  right  side  of  the  trunk  generally  was  hyper- 
aesthetic,  and  cold  produced  an  extremely  painful  impres- 
sion upon  him.  The  treatment  consisted  of  rest,  but 
not  absolute  ;  iodide  of  potassium  in  full  doses,  with 
moderate  quantities  of  iron  and  strychnine.  Under 
this  plan  he  gradually  improved,  was  able  to  return  to 
India  at  the  expiration  of  his  leave,  and  is  now  in  the 
full  exercise  of  his  military  duties. 

Case  8.  Compression  and  Coficussion  of  Cervical 
Spine,  from  Blow  on  Head — Paraplegia — Slozv  Recov- 
ery.— J.  S.,  aged  46,  consulted  me  on  December  11, 
1868.  He  was  a  tall,  strong,  healthly-looking  man.  He 
stated  that  on  hurriedly  quitting  a  steamer  between 
decks  at  Aspinwall  he  struck  the  top  of  his  head  vio- 
lently against  the  under  side  of  a  deck  beam,  so  that  it 
appeared  as  if  he  had  jammed  his  head  down  between 
his  shoulders.  He  fell  forward  on  his  face,  did  not  lose 
consciousness,  but  was  instantly  aware  of  being  com- 
pletely paralysed  everywhere  below  the  neck.  He  lost 
all  power  except  that  of  speech.  The  paralysis  of  mo- 
tion was  complete  in  all  the  four  limbs.  He  could  not 
move  a  finger  or  toe.  He  had  no  uneasy  sensations  or 
pain  of  any  kind.  He  passed  water  voluntarily,  could 
retain  it,  and  could  control  the  action  of  the  bowels. 
The  accident  happened  on  April  18,  1867.  He  was 
carried  across  the  Isthmus  of  Panama,  went  on  to  Cali- 
fornia, perfectly  powerless  all  the  way.  He  did  not 
suffer  at  any  time  from  priapism,  but  he  continued  to 
be  impotent  for  more  than  a  year.  When  he  arrived 
at  San  Francisco,  on  the  2nd  May,  he  was  quite  power- 
less, but  he  soon  began  to  regain  some  motion  in  the 
lower  limbs,  and  in  the  course  of  a  month,  was  able  to 
walk  a  little.  From  this  time  his  walking  power  gradu- 
ally increased,  and  he  began  to  regain  power  in  his 
hands,  principally  in  the  left.     He  began  to  be  able  to 


SEVERE   BLOWS   ON   THE   SPINE.  45 

write  again  in  July,  but  the  character  of  his  handwriting 
was  entirely  changed.  During  this  period  he  lost  about 
20  lbs.  in  weight,  of  which  he  had  since  regained  a  con- 
siderable portion.  There  was  little  treatment  adopted 
except  rest.  On  examination  I  found  the  following 
condition  : — The  spine  was  kept  straight,  had  lost  its 
flexibility,  and  could  not  be  moved  without  considerable 
pain.  There  was  tenderness  on  pressure,  and  on  move- 
ment the  first,  second,  third,  and  fourth  dorsal  vertebrae. 
In  pressing  on  this  part  of  the  spine  he  said  that  he  felt 
pains  shoot  down  the  limbs  into  his  feet.  When  he 
walked  he  felt  the  jar  of  the  pavement,  and  suffered 
much  if  it  was  at  all  irregular.  If  he  attempted  to 
write  for  any  time  he  was  seized  with  much  stiffness 
and  uneasy  crampy  sensations  in  his  right  hand  and 
arm.  His  general  health  was  good,  his  pulse  quiet. 
He  suffered  much  from  coldness  of  the  extremities. 
He  was  put  upon  a  course  of  the  iodide  of  potassium 
under  which  he  rapidly  improved. 

Case  9. — Direct  Blow  oit  Back  by  Fall — Slozv  Devel- 
opment of  Paralytic  Symptoms. — J.  W.,  aged  55,  con- 
sulted me  July  18,  1871.  Three  and  a  half  years 
ago  he  met  with  an  accident  at  New  York,  falling  five 
feet  on  his  back  on  to  a  pile  of  rough  stones.  He  was 
not  stunned,  and  no  ill  effects  were  felt  at  the  time,  or 
for  about  three  months  afterwards,  during  which  period 
he  went  about  his  business  as  usual,  being  a  minister 
in  a  Methodist  Church.  The  first  symptom  he  com- 
plained of  was  loss  of  sleep.  He  was  unable  to  sleep 
more  than  three  hours  at  a  time.  He  then  suffered 
from  extreme  mental  depression,  became  hypochon- 
driacal and  suicidal.  He  was  extremely  nervous,  so 
that  he  could  not  with  comfort  be  left  alone.  He  then 
began  to  walk  with  difficulty,  especially  when  attempt- 
ing to  go  up  or  down  stairs.  He  suffered  some  trouble 
about  the  bladder,  over  which  he  partially  lost  control. 
Great  tenderness  came  on  in  the  spine,  in  the  neck,  and 
across  the  loins.  He  suffered  a  good  deal  from  numb- 
ness, and  tingling  sensations  in  the  left  thigh.  His  feet 
readily  became  cold,  and  his  bowels  were  extremely 
costive.     By   rest   he   improved   somewhat.     He   was 


46  ON   CONCUSSION   OF  THE   SPINE. 

advised  to  go  into  the  country,  to  be  in  the  open  air,  and 
to  try  gardening.  This  made  him  very  materially 
worse.  He  had  increased  in  weight,  being  about  twelve 
pounds  heavier  than  he  was.  When  I  saw  him  he  was 
suffering  from  extreme  weakness,  and  constant  feeling 
of  exhaustion.  There  was  no  energy  left ;  he  could  do 
no  work,  mental  or  bodily.  He  slept  badly,  but  better 
than  he  did  some  time  ago.  He  walked  slowly  and  very 
feebly.  He  could  manage  about  two  miles  in  the  course 
of  the  day,  always  using  a  stick.  He  went  up  or  down- 
stairs with  great  difficulty,  and  easily  tripped.  He  suf- 
fered much  from  a  burning,  pricking  sensation  in  the 
left  leg  and  thigh,  but  there  appeared  to  be  no  differ- 
ence in  the  strength  of  the  two  limbs.  There  was  no 
affection  of  the  sphincters.  His  limbs  were  somewhat 
wasted.  The  sight  was  weak,  but  it  was  so  before  the 
accident.  The  spine  was  extremely  tender  over  the 
seventh  cervical  vertebra  and  the  lower  lumbar  region. 
There  was  also  some  tenderness  over  the  occiput  and 
the  sacro-iliac  articulation.  He  was  ordered  the  phos- 
phates of  iron,  quinine,  and  strychnine,  a  generous 
diet,  and  complete  rest. 

Case  10. — Direct  Blow  on  Back  by  Fall  Downstairs 
— Slow  Development  of  Symplons  of  Meningeal  Irrita- 
tion and  of  Paralysis, — Mrs.  E.,  aged  45,  consulted  me 
on  December  31,  1869.  Three  and  a  quarter  years  pre- 
viously she  fell  down  eighteen  stairs,  having  at  the 
time  her  arms  full  of  clothes.  Her  feet  slipped,  she 
fell  on  her  back,  and  bumped  down  the  stairs.  She  was 
not  stunned,  but  her  back  was  severely  struck.  She  got 
up  and  walked  some  distance.  She  did  not  keep  her 
bed,  and  did  not  think  much  of  the  accident,  except 
that  she  continued  from  time  to  time  to  suffer  pain  in 
the  lower  part  of  the  back.  This  had  continued  ever 
since  ;  she  had  never  been  free  from  it.  She  complained 
that  her  memory  was  impaired,  that  she  forgot  dates  ; 
she  could  not  recollect  where  she  placed  things,  and 
occasionally  she  used  the  wrong  word  or  forgot  a  par- 
ticular word  she  wished  to  employ  when  talking.  She 
was  apt  to  lose  the  thread  of  her  sentence  so  as  to  have 
to  begin  it  again.     Her  sleep  was  greatly  disturbed  by 


SEVERE   BLOWS   ON   THE   SPINE.  4/ 

dreams  of  a  terrifying  character.  There  were  constant 
noises  in  the  head,  slight  deafness  of  the  right  ear.  Any 
sudden  or  loud  noise,  such  as  the  crying  of  children  or 
the  falling  of  fire-irons,  distressed  her  extremely.  The 
sight,  smell,  and  taste  were  unaffected.  She  suffered 
much  from  pain  at  the  back  of  the  neck  and  across  the 
top  of  the  head.  Fatigue  and  excitement  increased  this 
pain  very  much.  Pressure  on  the  spine,  rotation  and 
antero-posterior  movement  occasioned  pain  over  the 
second  and  seventh  cervical  and  second  and  third 
lumbar  vertebrae.  The  right  hand  was  numb,  and  she 
had  pricking  sensations  in  the  fingers.  She  had  a  diffi- 
culty in  writing  and  in  taking  up  small  objects.  The 
other  limbs  were  free  from  all  uneasy  sensations.  The 
hands  were  cold,  the  appetite  bad,  and  she  had  lost 
flesh  considerably.  She  was  ordered  bromide  of  potas- 
sium at  night,  small  doses  of  iron  and  strychnine  in  the 
day,  and  belladonna  embrocation  for  the  back. 

Case  ii. — Concussion  of  Spine  front  Direct  Violence 
— Condition  of  Patient  Sixteen  Years  after  Injury. — 
J.W.  A.  S.,  aged  37,  from  Rhode  Island,  U.S.A.,  con- 
sulted me  on  June  29,  1869.  He  stated  that  at  a  fire 
in  June,  1853,  sixteen-  years  previously,  some  bricks 
fell  from  a  chim.ney  and  struck  him  on  his  back.  He 
was  knocked  down  by  the  blow,  and  was  laid  up  for 
several  months.  He  slowly  improved,  but  continued  to 
be  extremely  weak  in  the  back,  so  that  although  he  was 
able  to  walk  he  could  not  raise  himself  up  if  lying  in 
the  recumbent  position.  The  left  arm  was  also  mate- 
rially weakened.  He  had  never  recovered  from  the 
effects  of  this  accident,  although  he  had  been  able  to 
lead  an  active,  intellectual  life,  attending  very  closely  to 
his  business.  Latterly,  however,  he  had  broken  down 
completely  in  health,  and  had  come  to  Europe  for  its 
recovery.  On  examining  him  I  found  that  he  com- 
plained of  his  head  being  heavy,  and  of  a  sensation  of 
weight  and  pressure  across  the  eyebrows,  increased  by 
stooping.  He  dreamed  much  at  night ;  he  was  affected 
by  sudden  loud  noises  ;  his  sight  was  weak  ;  he  wore 
glasses,  and  suffered  a  good  deal  from  muscat  volitantes. 
The  left  eye  was  particularly  weak,  and  there  appeared 


48  ON   CONCUSSION   OF  THE   SPINE. 

to  be  some  amblyopia.  The  spine  was  slightly  tender 
in  the  middle  of  the  dorsal  region.  His  hands  were 
both  numb,  but  more  especially  the  left  one.  He  suf- 
fered a  good  deal  from  pricking  sensations  at  the  end 
of  the  fingers,  especially  in  the  left  index.  He  also 
complained  of  darting  pains  in  the  legs,  with  sudden 
spasmodic  twitchings,  tingling,  and  uneasy  sensations  in 
the  feet  and  toes,  with  occasional  cramps.  He  suffered 
a  good  deal  at  any  attempt  at  bending  up  the  foot. 

Case  12. — Slozvly  Developed  Spmal  Meningitis,  from 
Direct  Injury  received  in  a  Railway  Collision,  terminat- 
ing eventually  in  Death. — R.  E.  M.,  about  27  years  of 
age,  a  post-ofifice  clerk,  was  injured  in  a  railway  collision 
on  June  23,  1866.  At  the  time  of  the  accident  he  was 
standing  up  in  the  post-ofifice  van.  He  was  violently 
struck  on  the  right  side  and  loin  against  the  edge  of 
the  table  in  the  carriage.  He  felt  giddy,  confused,  and 
faint,  but  did  not  lose  consciousness.  For  a  day  or 
two  he  was  obliged  to  give  up  his  work,  but  in  the  course 
of  a  few  days  was  sufificiently  recovered  to  be  able  to 
make  a  journey  to  Preston  and  back.  The  pain  in  the 
back  at  the  part  struck  gradually  increased.  He  suffered 
much  from  tenderness  in  the '  spine,  in  the  lumbar 
region  ;  his  health  broke  down,  and  he  became  so  much 
enfeebled  as  to  be  obliged  to  take  to  his  bed.  He  was 
seen  by  Dr.  Waller  Lewis,  and  afterwards  by  Sir  James 
Paget.  These  gentlemen  recognized  a  severe  injury  to 
the  structures  of  the  spine  at  the  part  struck.  He  was 
ordered  complete  rest,  mercurials  in  small  doses,  and 
the  application  of  two  or  three  leeches  daily  to  the 
spine.  This  treatment  was  continued  until  the  end  of 
October  1866,  by  which  time  he  had  had  between  70 
and  80  leeches  applied  with  very  great  relief  after  each 
application.  The  pain,  however,  returned  severely  in 
two  or  three  days  if  the  leechings  were  discontinued. 
I  saw  the  patient  in  consultation  with  Dr.  Lewis  on 
November  3.  He  was  then  lying  in  bed,  looked  pale, 
worn,  and  haggard  in  the  face,  and  appeared  to  be  ten 
or  fifteen  years  older  than  he  really  was.  On  examining 
him  we  found  that  he  was  unable  to  stand  without 
holding  to  a  chair  or  table.     Whilst  standing  he  kept 


SEVERE    BLOWS    ON   THE    SPINE.  49 

his  feet  far  apart  in  order  to  steady  himself  with  a 
broader  basis  of  support.  The  muscles  of  the  back  on 
the  right  side  of  the  lumbar  vertebrae  were  rigid  and 
contracted.  Ha  suffered  much  pain  on  pressure  in  the 
dorsal  and  lumbar  regions  of  the  spine,  but  particularly 
about  the  second  or  third  lumbar  vertebrae.  He  com- 
plained of  pain  shooting  down  the  outside  of  the  thighs. 
The  pain  in  the  spine  was  greatly  increased  on  any 
exertion  or  movement,  more  especially  if  he  attempted 
to  stoop  to  pick  up  anything.  In  doing  so  he  did  not 
bend  the  spine,  but  went  down  upon  his  knees,  keeping 
the  spine  straight.  He  suffered  great  pain  when  his 
shoulders  were  pressed  downwards,  and  especially  if 
there  was  any  attempt  at  rotation  or  at  bending  back- 
wards. He  slept  badly,  seldom  more  than  half  an  hour 
at  a  time,  starting  up  in  terror.  Street  noises,  the 
shaking  of  the  house  by  the  passage  of  a  heavy  wagon, 
the  slam  of  a  door,  all  jarred  and  alarmed  him  greatly. 
There  was  no  loss  of  sensation  in  the  legs,  but  he  com- 
plained of  creeping  feelings  and  of  pins  and  needles. 
He  was  ordered  the  iodde  of  potassium  and  bark,  ab- 
solute rest  and  good  diet.  I  saw  the  patient  again  on 
February  6,  1867,  in  consultation  with  Dr.  Lewis,  Dr. 
Webb,  and  Mr.  Holden.  He  stated  that  he  was  no 
better  than  at  the  last  visit,  and  Indeed  he  looked 
worse.  He  was  wan,  pallid,  almost  livid  in  the  face  ; 
his  pulse  was  quick  and  intermittent  about  once  in 
every  forty  beats.  There  was  a  good  deal  of  twitching 
of  both  arms,  but  more  especially  of  the  right  one. 
His  urine  had  escaped  Involuntarily  on  three  or  four 
occasions,  and  he  had  more  than  once  lost  control  over 
the  sphincter  ani.  On  examining  the  spine  we  found 
that  It  was  much  In  the  same  condition  as  at  the  last 
visit.  There  was  some  tenderness  in  the  upper  dorsal 
region  ;  then  an  absence  of  pain  along  the  spinous  pro- 
cesses ;  and  then  extreme  tenderness  on  pressure  over 
the  first,  second,  and  third  lumbar  vertebrae.  Movement 
of  any  kind  or  in  any  direction  aggravated  his  suffer- 
ings in  these  situations  very  greatly.  The  muscles  of 
the  spine  on  the  right  side  were  very  prominent  and 
hard,  those  on  the  left  soft  and  flattened,  so  that  a  very 

4 


so  ON   CONCUSSION   OF   THE   SPINE. 

considerable  difference  presented  itself  in  the  examin- 
ation of  the  back  on  the  two  sides.  He  could  only 
walk  with  difficulty,  and  with  the  aid  of  a  stick.  He 
dragged  the  left  foot,  which  was  considerably  everted, 
he  could  not  raise  the  toes  off  the  ground.  On  exam- 
ining the  leg  we  found  that  the  extensor  and  peroneal 
muscles  were  those  that  were  chiefly  paralyzed.  There 
was  a  good  deal  of  numbness  and  loss  of  sensation  over 
the  whole  of  the  left  side  of  the  body,  but  especially 
in  the  left  leg.  These  symptotns  came  on  about  three 
weeks  previously,  and  had  been  gradually  increasing. 
I  saw  him  again  in  the  following  June.  He  had  been 
in  the  country  for  some  length  of  time,  but  had  not 
improved  in  health.  He  was  extremely  weak  and  had 
almost  completely  lost  power  of  his  limbs.  The  pulse 
was  from  86  to  90,  very  feeble  and  intermittent.  He 
could  not  sleep  continuously,  owing  to  frightful 
dreams.  He  walked  with  very  great  difficulty,  leaning 
ou  a  stick  and  with  his  legs  widely  apart;  the  left  leg 
was  kept  straight  with  the  foot  everted.  He  suffered 
a  good  deal  from  cramps  in  the  leg,  more  especially  in 
the  left  one,  and  complained  greatly  of  pain  if  it  was 
moved  away  from  the  side  or  bent.  Latterly  he  had 
suffered  from  sickness  and  occasional  vomiting,  twice 
or  thrice  in  the  course  of  the  week.  After  the  con- 
clusion of  the  legal  proceedings  connected  with  the  case, 
I  lost  sight  of  the  patient,  who  retired  into  the  coun- 
try;  but  Dr.  Waller  Lewis  informed  me  in  1871  that 
he  had  eventually  died  from  the  effects  of  the  accident. 
The  particulars  of  the  latter  period  of  his  illness  and  of 
his  death  could  not  be  obtained. 

Case  13. — Severe  Contusion — Paraplegia — -Unsuspected 
Laceration  of  Intervertebral  Ligaments — Death  on  Ninth 
day. — J.  R.,  a  clerk  by  occupation,  was  admitted  under 
my  care  into  University  College  Hospital,  October  2, 
1862.  He  had  been  knocked  down  half  an  hour  pre- 
viously by  a  Hansom  cab,  the  horse  falling  partly  upon 
him  and  striking  him  on  the  neck  with  its  knee.  He 
never  lost  consciousness,  but  being  quite  unable  to 
move,  was  carried  to  the  hospital ;  on  his  way  he  passed 
his  urine  and  faeces  involuntarily. 


SEVERE   BLOWS   ON   THE   SPINE.  5 1 

On  examination  after  admission  it  was  found  that  he 
had  an  abrasion  and  ecchymosis  on  the  left  side  of  the 
neck.  There  was  no  inequaUty  or  irregularity  about 
the  spinous  processes,  or  any  evidence  of  fracture  of  the 
spine,  but  the  patient  complained  of  severe  pain  at  the 
seat  of  the  bruise.  There  was  complete  paralysis  of 
sensation  and  of  motion  in  the  lower  extremities  and 
the  trunk  as  high  as  the  shoulders,  and  incontinence  of 
faeces,  retention  of  urine.  The  breathing  was  wholly 
diaphragmatic.  He  was  quite  conscious,  and  gave  a 
description  of  the  accident.  He  had  suffered  from 
urethral  stricture  for  thirty-three  years,  so  that  only  a 
No.  5  catheter  conld  be  passed. 

On  the  following  day  his  state  was  much  the  same. 
He  complained  of  great  pain  in  the  right  arm  and  hand, 
which  were  bruised.  He  said  he  thought  he  was  para- 
lyzed, as  he  could  not  move  his  legs ;  but  on  being 
pressed  to  do  so,  after  some  difficulty  he  succeeded  in 
raising  both  legs,  and  in  crossing  them.  Sensation 
appeared  to  be  completely  lost.  His  most  distressing 
sensation  was  a  feeling  of  tightness  as  of  a  cord  tied 
tightly  round  the  abdomen  below  the  umbilicus. 

5th. — He  had  slept  well,  and  was  able  to  move  his 
legs  with  less  difficulty.  Pulse  64  strong;  passes  faeces 
involuntarily.  Urine  drawn  off,  and  was  ammoniacal. 
He  was  placed  on  a  water  mattress,  as  his  back  was 
becoming  excoriated.     Ordered  quinine  and  acids. 

8th.— Was  able  to  move  his  head  and  neck  from  side 
to  side.  Had  less  pain.  Urine  more  ammoniacal ; 
faeces  passed  involuntarily.  Bed-sores  over  sacrum  had 
much  extended. 

loth. — Difficulty  of  breathing  came  on,  but  was  re- 
lieved by  the  nth.  On  the  12th  it  returned,  with  mu- 
cous rales,  and  he  died  that  night — ten  days  after  the 
accident. 

On  examination  after  death  the  head  and  brain  were 
found  uninjured  and  healthy.  On  exposing  the  verte- 
bral column,  it  was  found  that  the  sixth  and  seventh 
cervical  vertebrae  had  been  separated  posteriorly.  The 
vertebrae  themselves,  and  their  arches,  were  quite 
sound,   but   there   was  a   fissure  without   any  displace- 


52  ON   CONCUSSION   OF   THE   SPINE. 

ment,  extending  through  the  articulating  processes  on 
the  left  side.  A  large  quantity  of  blood  was  extrava- 
sated  into  the  spinal  canal,  lying  between  the  bones 
and  the  dura  mater.  There  was  a  considerable  quan- 
tity of  reddish  serous  fluid  in  the  arachnoid.  The  pia 
mater  of  the  cord  had  some  blood  patches  upon  it  on 
the  lower  cervical  region.  The  cord  itself  was  quite 
healthy. 

In  this  case  it  will  be  observed  that  the  paralysis  was 
most  extensive,  as  much  so  as  is  compatible  with  life. 
The  loss  of  sensation  appeared  to  be  more  complete 
than  that  of  motion,  the  patient  being  able,  by  an  effort 
of  the  will,  to  cross  his  legs,  but  he  could  not  feel  when 
they  were  pinched  or  pricked.  The  fracture  of  an  ar- 
ticulation without  displacement  was  an  accidental  and 
insignificent  complication,  the  real  injury  consisting  in 
the  extravasation  of  blood  within  the  vertebral  canal, 
which,  by  compressing  the  cord,  induced  the  paralysis, 
that  ultimately  proved  fatal ;  death  being  doubtless 
hastened  by  the  effusion  of  a  large  quantity  of  serous 
fluid  from  the  irritated  arachnoid. 

The  primary  symptoms  of  concussion  of  the  cord 
immediately  and  directly  produced  by  a  severe  blow 
upon  the  spine  will  necessarily  vary  in  severity  and  ex- 
tent according  to  the  situation  of  the  injury,  the  force 
with  which  it  has  been  inflicted,  and  the  amount  of 
organic  lesion  that  the  delicate  structure  of  the  cord 
has  sustained  by  the  shock  or  jar  to  which  it  has  been 
subjected. 


LECTURE  III. 

ON  THE   SYMPTOMS   OF   SEVERE   CONCUSSION   OF  THE 
SPINE   FROM   DIRECT  VIOLENCE. 

The  effects  of  a  direct  blow  on  the  spine,  producing 
concussion  of  the  spinal  cord,  will  necessarily  vary  very 
greatly  according  to  the  part  that  is  struck. 

It  is  quite  possible  to  suppose  that  a  direct  blow  on 


CONCUSSION   OF  SPINE   FROM   VIOLENCE.  $3 

the  cervical  spine  may  give  rise  to  instantaneous  death 
without  dislocation  or  fracture  of  the  column.  But  it 
is  very  important  to  bear  in  mind  that  a  fracture  or 
even  partial  dislocation  may  exist  unsuspected — the 
case  being  considered  one  of  simple  contusion — and 
that  after  a  few  hours  or  days  a  suddenly  fatal  result 
may  occur  from  pressure  of  the  cord  above  the  fourth 
cerevical  vertebra,  from  change  in  the  displacement. 
The  two  following  cases  illustrate  the  fact. 

Case  14. — Severe  Contusion — Slight  Paralysis — Un- 
suspected Dislocation  between  the  Second  a?id  Third  Ver- 
tebrce — Sttddeji  Death  on  Fourth  Day. — W.  W.,  aged  34, 
a  carpenter,  was  admitted  into  University  College 
Hospital,  May  16,  for  injuries  sustained  while  getting 
out  of  a  train  before  it  had  stopped,  by  falling  between 
the  platform  and  the  carriages.  When  picked  up  he 
was  sensible,  and  complained  of  pain  in  his  right 
arm ;  and  it  was  noticed  that  he  had  had  a  motion. 

On  admission  he  was  found  in  the  following  condi- 
tion : — There  was  an  incised  wound  on  the  left  side  of 
the  head,  a  hsematoma  of  the  left  upper  eyelid,  and  a 
fracture  of  the  right  clavicle  at  the  junction  of  its  mid- 
dle and  outer  thirds.  There  was  also  extensive  bruis- 
ing of  the  upper  two-thirds  of  the  right  arm  ;  and,  on 
palpation,  the  fingers  could  easily  be  placed  all  round 
the  shaft  of  the  humerus  just  above  the  insertion  of 
the  deltoid,  the  skin  only  intervening.  The  left  del- 
toid was  paralyzed,  and  the  power  of  supinating  the 
left  hand  was  impaired.  There  was  no  local  bruising 
about  the  left  shoulder  to  account  for  this  paralysis,  nor 
was  their  any  pain  on  passive  movement.  There  was  a 
line  of  bruising  running  across  the  chest  from  the  right 
axilla  to  the  left  side  of  the  sternum,  at  the  level  of  the 
second  and  third  ribs.  All  the  movements  of  the  lower 
extremities  were  perfect,  and  the  patient  had  complete 
control  over  his  bladder.  When  sitting  up,  he  com- 
plained of  pain  in  his  neck,  which  was  relieved  by  sup- 
porting the  right  arm.  He  was  put  to  bed  flat  on  his 
back,  his  head  was  steadied  by  sand-bags,  and  the  right 
arm  was  placed  in  a  sling. 

May    17. — Very  thirsty    during   the   night;  did  not 


54  ON  CONCUSSION   OF  THE  SPINE. 

not  sleep.  1 1  A.M.:  Temperature  ioo'8°  F. ;  pulse  120; 
sweating  profusely.  11.30  P.M.:  Pulse  132;  sweating 
profusely ;  slept  after  twenty  grains  of  chloral  hydrate. 

1 8th. — Thirst  still  continues.  10  A.  M. :  Temperature 
ioo*4°;  pulse  120;  respiration  36.  6.10  P.M.:  Temper- 
ature 101°;  pulse  124;  respiration  36.  During  the 
night  he  was  very  restless,  kicking  of  the  bedclothes ; 
did  not  sleep  after  twenty  grains  of  chloral  hydrate, 
nor  after  a  draught  containing  twenty  grains  of  bro- 
mide of  potassium  and  twenty  drops  of  tincture  of 
hyoscyamus. 

19th. — I  A.  M. :  Respiration  hurried.  Patient  very 
restless ;  answers  rationally  when  spoken  to  ;  does  not 
complain  of  pain  anywhere.  10.30  A.  M. :  He  got  very 
little  sleep  last  night.  Face  and  finger-nails  dusky ; 
alae  nasi  working  ;  respiration  zi4 ;  pulse  96  ;  sweat  stand- 
ing in  drops  on  his  face  ;  mucus  rattles  in  the  throat. 
He  complained  greatly  of  his  head  being  so  low ;  he 
was  then  raised  up  into  a  half-sitting  posture,  and  sup- 
ported there  with  a  bed-rest.  He  said  he  felt  much 
better  and  more  comfortable,  when  all  of  a  sudden  his 
pulse  at  the  wrist  stopped,  his  head  fell  forwards  and 
to  the  right  side,  his  breathing  stopped  and  he  was  ap- 
parently dead.  The  bed-rest  was  at  once  removed,  an 
ounce  of  brandy  was  given  by  the  rectum,  and  artificial 
respiration  was  begun.  The  conjunctiva  was  insensible 
to  touch ;  pupils  equal,  small,  and  insensible  to  light. 
In  a  short  space  of  time  he  began  to  breathe  in  a  short, 
catching  way.  The  pulse  returned,  and  the  conjunc- 
tiva became  sensitive ;  pupils  reacted  to  light,  and  fin- 
ally he  was  completely  restored  to  consciousness  and  was 
apparently  as  well  as  he  was  before.  In  a  few  minutes 
he  began  struggling  and  kicking  his  legs  about  with 
great  violence  ;  he  soon  became  quiet,  and  asked  where 
he  was,  and,  when  told,  was  satisfied.  Three  minutes 
later  he  was  evidently  dead.  Artificial  respiration  was 
again  resorted  to,  and  brandy  given  by  the  rectum,  but 
without  success. 

Autopsy, — The  second,  third,  and  fourth  ribs  on  the 
right  side  were  broken  at  their  points  of  greatest  con- 
vexity.   The  greater  part  of  the  lower  lobe  in  each  lung 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  55 

was  collapsed.  There  was  an  ante-mortem  clot  in  the 
right  auricular  appendix.  No  injury  to  any  of  the  ab- 
dominal viscera.  There  was  no  fracture  of  the  skull, 
but  a  slight  recent  haemorrhage  was  found  beneath  the 
parietal  layer  of  the  arachnoid  ;  brain  healthy.  On  re- 
moving the  trachea  and  oesophagus,  very  extensive 
extravasation  was  found  in  the  loose  cellular  tissue 
behind  them,  and  a  dislocation  of  the  cervical  spine 
between  the  second  and  third  vertebrae,  the  greater 
part  of  the  inter-vertebral  cartilage  being  adherent 
to  the  third  vertebra.  The  ligamentous  structures  were 
more  lacerated  on  the  left  than  on  the  right  side,  so 
that  while  lateral  displacement  of  the  upper  part  of  the 
spine  to  the  right  was  possible,  that  to  the  left  was  not 
much  more  than  natural ;  excessive  displacement  in  the 
antero-posterior  direction  easily  occurred,  and  in  either 
case,  but  especially  when  moved  forwards,  there  was 
pressure  on  the  cord.  In  the  right  upper  extremity 
the  biceps  and  brachialis  anticus  muscles  were  torn 
across  without  the  humerus  being  broken,  and  the  cla- 
vicle was  broken  at  the  junction  of  the  outer  and  mid- 
dle thirds. 

The  interesting  points  in  this  case  were : — That  on 
admission  he  evinced  no  sign  of  head  injury,  nor  of 
paralysis  generally ;  but  in  the  left  upper  extremity  he 
had  lost  power  over  the  deltoid  and  supinator  muscles. 
2.  That  there  was  a  dislocation  between  the  second  and 
third  cervical  vertebrae.  3.  That  the  man  lived  so  long, 
a  point  of  great  medico-legal  interest,  because  it  shows 
that  such  an  injury  may  be  survived.  On  visiting  him 
I  came  to  the  conclusion  that  he  had  sustained  an  in- 
jury to  the  cord  in  the  cervical  region,  and  that  this 
was  the  cause  of  the  paralysis  of  a  portion  of  the  bra- 
chial plexus,  the  circumflex  and  the  musculo-spiral 
being  the  nerves  that  were  paralysed.  This  clearly 
])ointed  to  a  central  origin,  which  could  only  be  at  the 
spinal  cord.  I  did  not  diagnose,  nor  even  suspect,  the 
peculiar  injury  of  which  he  died,  because  it  is  very  rare 
and  of  very  unusual  character.  The  head  and  two  first 
cervical  vertebrae  were  dislocated  from  the  third  cervical 
vertebra,  and   the   dislocation  was  complete,  the  arti- 


56  ON   CONCUSSION   OF  THE   SPINE. 

culating  processes  being  unbroken.  But  the  same  may 
happen  when  a  cervical  vertebra  is  broken  but  not  dis- 
placed. 

Case  i  5 . —  Unsitppected  Fracture  of  Spinous  process  of 
fifth  Cervical  Vertebra — Displacement  and  Sudden  Death. 
— A  woman  was  admitted  into  University  College  Hos- 
pital suffering  from  the  effects  of  a  fall  on  the  back,  the 
circumstances  attending  which  were  obscure.  There 
was  no  head  injury  or  head  symptoms  and  no  paralysis. 
But  she  complained  of  pain  in  the  neck,  and  kept  the 
head  fixed  immovably,  being  quite  unable  to  turn  it  to 
either  side.  A  few  days  after  admission,  whilst  sitting 
up  in  bed,  she  was  startled  by  a  noise  in  the  ward, 
turned  her  head  suddenly  to  see  what  had  occasioned 
it,  and  fell  back  dead. 

At  the  autopsy  it  was  found  that  the  spinous  process 
of  the  fifth  cervical  vertebra  had  been  broked  off  at  its 
root.  In  the  sudden  movement  it  had  got  jammed  into 
the  space  between  the  arches  of  that  and  the  conti- 
guous vertebra,  compressed  the  cord,  and  produced 
sudden  death. 

These  two  cases  are  important  from  a  medico-legal 
point  of  view,  as  showing  that  notwithstanding  the  inflic- 
tion of  an  injury  of  a  fatal  character,  life  may  be  pro- 
longed for  several  days  until  death  is  brought  about  by 
accidental  movement. 

Injury  to  the  spine  that  is  by  its  very  nature  fatal 
may  occur  without  any  direct  blow  on  the  spine  itself, 
but  from  falls  on  the  head.  Thus  I  have  seen  a  case  in 
which  a  man  fell  on  his  vertex  out  of  a  window.  There 
was  extravasion  under  the  scalp,  but  no  fracture  of  the 
skulk  The  only  sign  of  nerve  injury  was  paralysis  of 
the  spinal  accessory.  Paralytic  symptoms  gradually 
invaded  the  limbs.  First  one  upper  extremity,  then 
the  other  became  paralyzed,  and  then  one  leg. 
After  death  the  atlas  was  found  broken  through  its 
left  lateral  mass,  and  the  cervical  portion  of  the  cord 
had  undergone  inflammatory  softening  and  central  dis- 
integration. 

But  if  the  injury  or  concussion  of  the  cervical  spine 
be  not  immediately  or  speedily  fatal,  it  may  lead  to 


CONCUSSION   OF  SPINE   FROM   VIOLENCE.  57 

more  or  less  complete  paralysis  of  the  body  generally, 
or  of  the  upper  extremities  only. 

The  paralysis  may  be  hemiplegic.  But  most  com- 
monly it  affects  the  arm  and  leg  on  one  side,  and  the 
leg  to  a  limited  extent  on  the  opposite  one,  or  there 
may  be  more  or  less  distinct  paraplegia.  In  injuries  of 
the  cervical  spine,  more  or  less  paralysis  and  spasm  is 
apt  to  be  developed  in  the  muscles  of  the  neck  and  of 
one  arm  ;  the  leg  being  often  but  very  slightly  if  at  all 
affected.  There  is  in  fact  every  possible  variety,  in  the 
extent,  degree,  and  relative  amount  of  paralysis  of  mo- 
tion and  of  sensation. 

Injuries  of  the  back  below  the  cervical  region,  unat- 
tended by  fracture  or  dislocation  of  the  spine,  are 
scarcely  ever  immediately  and  not  very  frequently  re- 
motely fatal.  But  they  are  apt  speedily  to  give  rise  to 
and  remotely  to  be  followed  by  a  long  train  of  more 
distressing  systoms. 

The  condition  that  is  most  frequently  developed  by 
a  direct  blow  on  the  middle  or  lower  dorsal,  the  lumbar 
or  lumbo-sacral  regions,  is  that  of  paraplegia. 

The  symptoms  presented  by  the  patient  who  is  thus 
paralyzed  below  the  seat  of  the  concussion  of  the  spine 
are  necessarily  those  which  result  from  such  a  disturb- 
ance, commotion,  or  lesion  of  the  cord  as  will  occasion 
serious  modification  or  complete  suspension  of  its  func- 
tions. 

In  these  primary  and  more  immediate  forms  these 
symptoms  are  of  the  following  kinds : 

1.  Diminution  or  loss  of  motor  power. 

2.  Rigidity  and  spasm  of  muscles. 

3.  Diminution  or  loss  of  sensation. 

4.  Perversion  of  sensation. 

5.  Loss  of  control  over  the  sphincters. 

6.  Modification  of  the  temperature  of  the  limb. 

I.  Diminution  or  loss  of  motor  power  is  usually  the 
most  obvious  and  marked  symptom. 

It  may  be  complete,  so  that  the  patient  is  quite 
unable  to  stand ;  or  it  may  be  limited,  affecting  only 
certain   sets   of  muscles,  and  that  to  a  comparatively 


58  ON   CONCUSSION   OF  THE   SPINE. 

slight  degree,  so  as  to  require  careful  examination 
to  determine  the  existence  of  any  loss  of  motor 
power. 

It  may  affect  the  two  limbs  equally  or  in  unequal  de- 
grees.    It  may  be  confined  entirely  to  one  limb. 

In  all  cases,  when  slight,  the  loss  of  power  is  most 
marked  when  the  patient  stands,  Avalks,  or  attempts  to 
run.  When  the  patient  is  recumbent  he  will,  though 
suffering  seriously  from  immobility,  yet  be  able  to 
draw  up  his  legs,  kick  them  out,  and  appear  to  possess 
complete  control  over  them.  But  these  movements 
come  from  the  thigh  and  knee,  and  not  from  the  leg 
and  foot. 

When  the  paraplegic  immobility  is  complete  or 
nearly  so,  there  is  necessarily  no  difficulty  in  determin- 
ing its  exisence.  But  when  the  loss  of  power  is  slight, 
and  especially  if  it  do  not  affect  the  limb  generally,  but 
is  confined  to  one  set  of  muscles,  it  becomes  more  diffi- 
cult to  determine  its  existence. 

In  these  circumstances  it  will  be  necessary  to  test 
the  patient's  motor  powers  more  carefully.  This  may 
be  done  by  telling  him  to  walk,  run,  stand  on  one  leg, 
or  go  up  and  down  stairs,  when  the  failure  in  power  in 
one  or  both  limbs  will  usually  at  once  declare  itself. 
He  totters  and  straddles  his  legs,  so  as  to  increase  his 
basis  of  support,  and  he  drags  one  foot,  being  unable 
to  raise  the  toe  fairly  from  the  ground. 

In  order  to  determine  the  precise  set  of  muscles  that 
are  affected,  we  have  two  tests,  viz.,  loss  of  voluntary 
motion,  and  the  determination  of  the  loss  or  diminu- 
tion of  the  electric  irritability  of  the  muscles. 

Any  one  of  the  muscles  connected  with  the  lower 
limbs  may  be  affected. 

In  some  cases  the  psoas  muscles,  and  apparently 
they  only,  are  paralyzed.  When  this  is  the  case  the 
patient,  when  once  erect,  can  stand  and  walk  fairly 
well ;  but  when  sitting  he  cannot  rise  off  his  chair  with- 
out the  uplifting  use  of  his  arms.  If  told  to  rise  with- 
out assisting  himself  with  his  hands  or  with  a  stick,  his 
contortions  are  most  painful  to  witness.  He  writhes 
about  in  the   chair,  presses  the   ground  with   his  feet, 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  59 

raises  his  legs,  bends  backwards  and  forwards,  but 
appears  to  be  immovably  fixed  in  his  seat  by  the  but- 
tocks. If  given  a  hand  or  aided  with  a  stick,  he  rises 
readily  and  stands  and  walks  well.  When  lying  flat  on 
his  back  he  cannot  raise  the  extended  limb  off  the 
couch.  He  can  bend  the  knee,  and  thus  draw  up  the 
leg,  but  he  cannot  extend  and  then  raise  it. 

I  have  never  met  with  a  case  in  w^hich  the  paralysis 
could  be  localized  in  and  was  confined  to  the  muscles 
of  the  thigh.  In  all  cases  where  the  anterior  crural 
and  obturator  nerves  were  affected  the  whole  of  the 
lumbo-sacral  plexus  seemed  to  have  participated  in  the 
paralytic  condition. 

But  it  very  frequently  happens  that  the  muscles  of 
the  leg  and  foot  are  affected  without  any  of  those 
above  the  knee  participating  in  the  loss  of  power. 

The  loss  of  power  below  the  knee  may  be  complete 
or  it  may  be  confined  to  one  or  other  of  the  sets  of 
muscles  that  move  the  foot.  When  complete  there  is 
no  dif^culty  in  determining  its  existence.  It  is  when 
incomplete  that  it  is  sometimes  dif^cult  to  determine 
the  degree  of  the  paralysis  and  its  precise  seat. 

In  order  to  ascertain  whether  there  is  motor  paraly- 
sis or  not,  it  must  be  borne  in  mind  that  the  foot  is 
capable  of  four  distinct  movements  at  the  ankle-joints; 
viz.,  I.  The  heel  may  be  raised  and  the  toe  pointed 
downwards.  2.  The  foot  mi  ay  be  turned  inwards — 
both  these  movements,  I  need  not  tell  you,  are  effected 
by  the  muscles  supplied  by  the  external  popliteal 
nerve.  3.  The  heel  may  be  depressed  and  the  toes 
raised.  4.  The  foot  may  be  turned  outwards.  These 
two  latter  movements  are  effected  by  the  muscles  sup- 
plied by  the  external  popliteal  or  peroneal  nerves. 

Now  the  readiest  means  of  determining  the  extent 
and  the  seat  of  the  motor  paralysis  in  the  leg  is  to 
place  the  patient  on  his  back,  to  extend  his  leg,  and 
then  to  steady  the  knee  by  grasping  it  in  one  hand  so 
that  he  may  not  turn  the  limb  involuntarily.  Next 
direct  him  to  point  his  toes,  then  to  turn  the  foot  in- 
wards, then  to  draw  up  his  toes,  and  lastly  to  turn  the 
foot  outwards.     lie  will  either  be  able  to  execute  all 


6o  ON   CONCUSSION   OF  THE   SPINE. 

the  movements  in  an  imperfect  degree — the  amount  of 
imperfection  depending  on  the  extent  of  the  paralysis 
— or  he  will  be  able  to  do  the  two  first,  which  are  under 
the  control  of  the  internal  popliteal  nerve,  but  not  the 
two  last,  which  are  under  the  direction  of  the  peroneal 
nerve.  It  is  a  remarkable  fact  that,  in  the  large  num- 
ber of  cases  in  which  I  have  made  the  experiment,  I 
have  never  met  with  one  in  which  power  is  lost  over 
the  muscles  supplied  by  the  internal  popliteal  nerve 
whilst  it  still  remained  in  those  supplied  by  the  pero- 
neal nerve.  On  the  other  hand,  the  number  of 
instances  in  which  loss  of  power  existed  in  the  muscles 
supplied  by  branches  of  the  external  popliteal  nerve, 
the  depressors  and  adductors  of  the  foot  retaining  their 
full  mobility,  has  been  very  great. 

It  will  generally  be  found  that  the  movement  which 
is  first  lost  in  cases  of  injury,  and  last  regained  in  cases 
of  recovery,  is  that  of  eversion  of  the  foot,  the  action 
of  the  peronei  muscles.  Next  to  this  the  action  that 
is  most  readily  impaired  is  that  which  is  under  the 
control  of  the  elevators  of  the  foot,  viz.,  the  depression 
of  the  heel  and  the  raising  of  the  foot  as  a  whole — not 
of  the  toes  only — for  that  power  will  exist  when  the 
other  is  lost. 

It  is  in  consequence  of  the  frequency  of  the  paralysis 
of  the  external  popliteal  nerve  in  cases  of  slight  para- 
plegia that  the  patient  in  walking  drags  the  toes,  and 
usually  turns  them  inwards.  He  is  unable  to  raise  the 
foot  so  as  to  clear  the  ground,  or  to  evert  it  properly. 
Hence  the  sole  of  his  boot  will  be  found  worn  away  at 
the  toes  and  not  at  the  heel,  and  more  at  the  inner 
than  at  the  outer  side. 

The  two  limbs  may  be  affected  in  this  way  as  nearly 
as  possible  to  the  same  extent.  When  one  limb  is 
more  paralyzed  than  the  other,  I  have  found  it  to  be 
most  frequently  the  left.  In  many  cases  it  alone  is 
affected,  the  right  leg  escaping  entirely. 

I  have  never  seen  opposite  sets  of  muscles  affected 
in  the  two  limbs.  If  both  limbs  are  paralysed,  the 
same  sets  of  muscles  are  always  involved,  though  in 
varying  degrees  of  intensity. 


CONCUSSION    OF    SPINE    FROM    VIOLFXCF.  Gl 

Jacoud  *  truly  says,  ^'  In  every  disease  of  the  nervous 
system,  and  of  the  muscular  system,  the  clinical  exami- 
nation is  not  complete  until  the  electric  investigation 
has  been  effected." 

The  electric  test  when  properly  applied  will  enable 
us  to  determine  not  only  diminution  or  complete  loss 
of  the  irritability  of  the  muscles  that  refuse  to  obey 
the  volition  of  the  patient,  but  also  the  varying  extent 
to  which  the  loss  has  proceeded  on  the  two  sides.  In 
employing  this  test,  it  is  important  always  to  compare 
the  irritability  of  the  same  muscles  in  the  opposite 
limbs — never  to  compare  the  irritability  of  a  flexor 
with  that  of  an  extensor  in  the  same  limb,  and  above 
all  not  to  compare  the  irritability  of  the  muscles  of  a 
lower  and  an  upper  extremity.  The  irritability  is,  as  a 
rule,  greater  in  the  latter  than  in  the  former. 

It  is  important  to  bear  in  mind  that  in  elderly  per- 
sons the  electric  irritability  of  the  musics,  especially  of 
the  lower  limbs,  is  often  considerably  diminished  with- 
out there  having  been  any  diminution  or  impairment 
of  innervation  from  injury. 

2.  Rigidity,  with  more  or  less  permanent  spasm  and 
contraction  of  certain  muscles,  is  frequently  met  with 
in  cases  of  spinal  injury.  It  is  often  associated  with 
hyperaesthesia.  The  muscles  that  are  most  commonly 
affected  in  this  way  are  the  flexors  of  the  limbs.  The 
extensors,  as  we  have  seen,  are  most  commonly  palsied, 
the  flexors  most  frequently  rigid  and  often  contracted. 
Next  in  frequency  to  the  flexors  of  the  limbs,  rigidity 
affects  the  trapezius  and  sterno-mastoid — the  muscles 
about  the  shoulders,  and  the  large  lateral  masses  of 
spinal  muscles.  These  will  frequently  be  seen  to  be 
rigid,  tense,  and  thrown  out  in  prominent  relief,  partly 
in  consequence  of  irritation  of  the  nerves  supplying 
them,  partly  also  in  a  reflex  or  instinctive  manner,  in 
order  to  protect  neighboring  or  subjacent  tender  parts. 
This  condition  of  the  muscles  is  usually  associated  with 
much  pain,  even  though  it  be  not  of  the  nature  of  cuta- 
neous hyperaesthesia ;  and  the  pain  is  greatly  increased 

*  Clinique  Mtdicale,  p.  339, 


62  ON   CONCUSSION   OF  THE   SPINE. 

in  any  attempt  at  stretching  or  moving  the  affected 
muscles.  Rigidity  and  painful  muscular  contraction 
may  be  looked  upon  as  indicative  of  meningeal  rather 
than  of  medullary  lesion. 

3.  Diminution  or  loss  of  sensation  probably  does  not 
occur  so  frequently  or  to  the  same  extent  as  impair- 
ment of  motor  power.  When  it  does  exist  to  a  slight 
or  limited  degree,  it  is  more  difficult  of  determination 
than  the  loss  of  free  motion. 

Like  paralysis  of  motion,  anaesthesia  may  be  general 
or  partial  below  the  seat  of  injury  to  the  spine.  It  may 
be  confined  to  one  nerve,  or  even  to  its  cutaneous 
branch.  When  this  is  the  case,  it  is  mostly  usually  the 
cutaneous  filaments  of  the  external  popliteal  that  are 
affected. 

The  extent  and  the  precise  area  of  the  impairment 
of  sensation  may  readily  be  determined  by  means  of 
the  aesthesiometer  of  Brown-Sequard,  or  an  ordinary 
pair  of  compasses — to  measure  the  limit  of  the  per- 
ception of  the  two  points — by  the  interrupted  electric 
current,  or  by  pulling  the  hairs  in  the  wrong  direction. 

4.  Pain  and  perverted  sensations  of  all  kinds  are 
very  common  in  cases  of  spinal  concussion  from  direct 
blows  on  the  back.  As  I  have  already  stated,  the  pain 
is  more  frequently  associated  with  muscular  contraction 
and  rigidity  than  with  palsy.  But  it  may  be  associated 
with  a  paralytic  state,  and  thus  the  combination  of 
neuralgia  and  paralysis  of  some  muscles,  with  more 
or  less  rigidity  of  others,  becomes  as  painful  for  the 
patient  to  bear  as  it  is  difficult  for  the  surgeon  to  ex- 
plain. 

Hyperaesthesia  of  the  most  intense  character  is  fre- 
quently found  associated  with  anaesthesia.  In  these 
cases  the  hyperaesthesia  extends  in  a  line  between  the 
parts  that  preserve  their  normal  sensibility  and  those 
that  are  anaesthetic.  Thus  in  cases  of  dorsal  injury  of 
the  spine,  there  may  be  a  hyperaesthetic  zone  round 
the  body,  with  more  or  less  complete  anaesthesia  of  the 
pelvis  and  lower  limbs.  In  injury  of  the  cervical  spine, 
there  may  be  a  hyperaesthetic  line  extending  down  the 
arms,  the  skin  on  one  side  of  the  limb  above  the  line 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  63 

being  normally  sensitive,  that  on  the  other  side  being 
completely  benumbed.  This  thoracic  or  abdominal 
zone  round  the  body,  or  perpendicular  line  of  hyper- 
aesthesia  down  a  limb,  corresponds  to  the  distribution 
of  the  nerves  that  are  given  off  from  the  spinal  cord  at 
the  seat  of  injury.  This  may,  as  a  rule,  be  taken  as  an 
indication  of  fracture  across  the  vertebral  column,  even 
though  there  be  no  displacement  of  the  bones.  It  is 
occasioned  by  the  irritation  of  the  nervous  trunks  by 
the  sharp  or  ragged  edges  of  the  fractured  portions  of 
bones,  in  their  passage  through  the  injured  portion  of 
the  spine. 

There  is  a  minor  degree  of  this  form  of  hyperaesthe- 
sia,  consisting  of  the  sensation  of  a  cord  tied  tightly 
round  the  body,  which  is  very  common  in  severe  blows, 
more  especially  in  wrenches  of  the  spine,  and  which 
seems  to  be  dependent  rather  on  pressure  on  the  nerves 
by  ligamentous  strain  than  by  bony  fracture.  The  fol- 
lowing case,  which  has  been  under  my  care  at  Univer- 
sity College  Hospital,  is  a  good  illustration  of  this  form 
of  hypersesthesia : 

Case  i6. — Injury  of  the  Spine  in  lower  Dorsal  Re- 
gion— Recovery  tvith  angular  Curvature. — About  10.30 
P.  M.  on  June  28th,  a  blacksmith,  aged  23,  was  seated 
on  the  top  of  a  pleasure-van,  when  the  driver  attempted 
to  pass  under  a  low  archway  leading  into  a  mews.  The 
patient  stooped  forwards,  the  edge  of  the  arch  struck 
the  lower  part  of  his  back,  and  he  was  thus  dragged 
through  the  archway,  forcibly  doubled  up  and  crushed 
between  it  and  the  top  of  the  van.  He  felt  at  once 
great  difficulty  in  breathing,  and  was  brought  to  the 
hospital.  When  seen,  a  few  minutes  after  the  acci- 
dent, the  patient  was  suffering  from  great  dyspnoea  ; 
the  breathing  was  almost  entirely  thoracic  ;  the  rectum 
had  been  emptied  involuntarily.  The  left  leg  was 
paralysed,  and  there  was  intense  hypersesthesia  over 
the  lower  part  of  the  thorax  and  back,  i.  e.,  below  the 
level  of  the  third  costal  cartilage,  as  well  as  over  the 
abdomen  and  the  upper  two-thirds  of  the  thighs.  Even 
slight  pressure  on  any  part  of  this  area  caused  intense 
pain,  and  firm  pressure  still  more.     Above  and  below 


64  ON   CONCUSSION   OF  THE   SPINE. 

the  limits  mentioned,  sensibility  was  apparently  normal. 
Opposite  the  spines  of  the  tenth,  eleventh  and  twelfth 
dorsal  vertebrae  there  was  a  considerable  prominence, 
which  terminated  abruptly  below  in  a  depression.  Ice- 
bags  were  ordered  to  be  applied  to  the  spine. 

June  29th. — There  was  still  dyspnoea,  but  the  patient 
could  draw  up  the  left  leg  in  bed  and  move  the  toes. 
The  hyperaesthesia  was  much  the  same  as  on  admission. 
The  patient  had  control  over  his  bladder ;  there  was  no 
priapism. 

June  30th. — On  more  careful  examination,  the  limits 
of  the  hyperaesthesia  were  as  follows :  On  the  front  of 
the  left  leg,  it  extended  to  three  inches  below  the  knee  ; 
on  the  right,  to  the  upper  border  of  the  patella ;  pos- 
teriorly, it  extended  to  the  middle  of  the  thigh  in  both 
limbs ;  above,  it  began  at  the  lower  border  of  the  ribs. 
The  patient's  breathing  was  rather  easier.  He  still 
complained  of  the  sensation  of  having  a  band  tied 
round  the  abdomen. 

July  1st. — Since  3  A.  M.  the  patient  has  had  painful 
twitchings  of  the  muscles  of  the  left  thigh,  especially  of 
those  in  front,  and  the  symptom  was  becoming  more 
troublesome.  The  hyperaesthesia  does  not  extend  so 
high  as  yesterday,  only  to  the  level  of  the  iliac  crests. 

July  2nd. — Pulse  60,  soft  and  regular ;  respirations, 
24;  temperature,  99^^.  The  patient  was  decidedly 
better.  The  hyperaesthesia  reached  from  the  level  of 
the  iliac  crests  to  the  upper  border  of  the  patella  in  the 
left  leg,  and  to  the  junction  of  the  middle  and  lower 
third  of  the  thigh  in  the  right.  The  twitching  of  the 
left  thigh  was  less.  The  patient  could  not  raise  either 
foot  from  the  bed,  but,  in  attempting  to  do  so,  the 
right  rectus  femoris  muscle  contracted  more  strongly 
than  the  left. 

July  3rd. — The  area  of  hyperaesthesia  had  again  dim- 
inished, the  difference  being  greater  below  than  above. 

July  8th. — The  hyperaesthesia^was  now  limited  to  the 
pubes  and  scrotum.  The  patient  still  had  the  feeling 
of  a  tight  band  round  the  abdomen,  bnt  it  was  less 
marked  than  it  had  been  before,  and  was  felt  at  a  lower 
level.     His  general  health  was  improving. 


CONCUSSION   OF   SPINE   FROM    VIOLENCE.  65 

July  i6th. — Tbe  hypersesthesia  was  now  confined  to 
the  scrotum,  and  chiefly  to  the  left  side.  The  sen- 
sation of  a  band  round  the  body  had  quite  disappeared. 

July  30th. — For  the  last  few  days,  the  patient  had 
been  up  and  about  the  ward  daily.  He  stooped  much 
when  standing  or  walking,  the  shoulders  being  rounded 
and  thrown  forwards.  There  was  some  angular  curva- 
ture of  the  spine,  the  ninth  dorsal  vertebra  standing 
out  most  prominently.  The  patient  was  discharged 
convalescent. 

Whether  there  was  in  this  case  actual  fracture  of  the 
spine,  or  partial  dislocation  with  laceration  of  liga- 
ments, or  both  combined,  could  not  be  stated  with 
certainty ;  but  there  was  considerable  contusion  of  the 
spinal  cord — the  motor  tract  being  slightly,  the  sensory 
more  severely  injured.  The  distribution  of  the  symp- 
toms, and  the  order  in  which  they  disappeared,  was 
interesting. 

Various  perversions  of  sensibility  are  met  with. 
Formications,  tinglings,  cramps,  '^  pins  and  needles," 
are  all  sensations  that  are  commonly  referred  to  the 
parts  below  the  seat  of  spinal  concussion.  They  will 
frequently  be  adverted  to  and  described  in  the  fol- 
lowing pages,  but  need  only  be  mentioned  here.  There 
is  one  peculiar  perversion  of  sensation  which  I  have 
several  times  observed  in  cases  of  paraplegia.  It  is 
this,  that  whilst  the  legs  are  lying  straight  and  par- 
allel to  one  another  the  patient  feels  as  if  they  were 
crossed  over  one  another  at  the  knees,  and  asks  to  have 
them  straightened. 

The  results  that  are  afforded  by  clinical  observation 
as  to  the  greater  frequency  of  the  loss  of  motor  power 
than  of  sensation  in  cases  of  concussion  of  the  spine 
from  direct  blows  on  the  back  are  explained  and  sup- 
ported by  the  physiological  investigations  and  dis- 
coveries of  Brown-Sequard.  This  distinguished  physi- 
ologist has  shown  that  the  motor  fibres  run  on  the 
exterior  of  the  cord  in  its  antero-lateral  columns, 
crossing  at  the  pyramids,  whilst  the  sensory  fibres  are 
situated  deeply  in  the  cord  running  to  the  grey  matter 
and  crossing  at  once  to  the  opposite  side.     Tlic  motor 

5 


66  ON  CONCUSSION   OF  THE   SPINE. 

fibres  then  being  most  superficial,  and  consequently 
more  exposed,  will  be  injured  by  accident  or  affected 
by  disease  more  readily  than  the  more  deeply-seated 
sensory  fibres.  If  the  injury  to  the  cord  be  slight,  or 
if  the  disease  be  superficial,  affecting  the  meninges 
chiefly  and  only  implicating  the  mere  exterior  layers  of 
the  medulla,  motor  power  will  alone  be  impaired ; 
whereas,  if  the  grey  matter  is  implicated  in  the  injury 
or  disease,  sensation  will  be  more  less  completely  lost, 
according  to  the  depth  and  extent  of  the  implication. 
And  if  the  grey  matter  on  only  one  side  of  the  cord  be 
affected  the  loss  of  sensibility  will,  owing  to  the  cross- 
ing of  the  fibres,  occur  on  the  opposite  side.  This 
explains  what  we  have  such  frequent  opportunities  of 
observing  in  those  cases  of  spinal  concussion,  namely, 
that  motion  may  alone  be  impaired,  that  it  is  affected 
to  a  greater  degree  than  sensation,  and  that  sensation 
may  be  diminished  in  the  limb  opposite  to  that  in 
which  motion  is  lost.  It  is  also  possible  to  conceive  that 
in  consequence  of  intra-spinal  haemorrhage  destroying 
or  compressing  the  gray  matter  alone,  sensation  might 
be  abolished  whilst  motor  power  remained  intact. 

This  has  actually  been  observed  in  some  cases  both 
of  injury  and  disease. 

The  various  combinations  of  motor  paralysis,  anaes- 
thesia, and  hyperaesthesia,  which  are  often  met  with 
in  cases  of  concussion  or  other  injury  of  the  cord,  may 
be  explained  by  the  results  of  the  experimental 
researches  of  Brown-Sequard,  w4io  has  found  that  in 
lesion  of  one-half  of  the  spinal  cord,  its  transverse  semi- 
section,  for  example,  there  will  be  paralysis  of  motion 
with  hyperaesthesia  of  the  injured  side  and  anaesthesia 
of  the  opposite  side  of  the  body.  If  the  posterior 
columns  be  divided  there  will  be  neuralgia  with  motor 
ataxy,  and  a  lesion  of  the  lateral  columns  will  produce 
paralysis  with  contracture  (Seguin).  It  is  by  reference 
to  the  results  of  experimental  researches  that  we  are 
thus  enabled  to  account  for  clinical  phenomena  that 
would  otherwise  be  utterly  inexplicable,  or  that  might 
be  considered  incorrectly  described  by  the  patient  or 
inaccurately  observed  by  the  surgeon. 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  6/ 

5.  Paralysis  of  the  sphincters  of  the  bladder  and 
rectum  is  an  extremely  uncertain  symptom.  It  is 
sometimes  met  with  in  comparatively  slight  cases, 
especially  when  the  blow  leading  to  the  concussion 
has  been  inflicted  low  down,  in  the  lumbar  and  sacral 
regions.  It  is  sometimes  absent  when  both  the  lower 
limbs  are  completely  paralyzed.  If,  however,  the  seat 
of  concussion  be  about  the  middle  dorsal  vertebrae,  and 
if  the  injury  be  severe,  it  is  always  present  to  a  greater 
or  less  degree. 

The  paralysis  may  be  confined  to  the  bladder  only. 
In  these  cases  there  may  be  complete  atony  with 
incontinence,  or  there  may  be  retention  with  or  without 
overflow  of  the  urine. 

There  would  appear  to  be  tw^o  forms  of  paralysis  of 
the  bladder  in  spinal  injuries.  In  one  there  is  a  con- 
tracted, in  the  other  a  dilated  state  of  the  organ.  In 
the  first  or  contracted  form  the  bladder  appears  to  be 
collapsed,  there  is  complete  incontinence,  the  bladder 
allov/ing  the  urine  to  flow  out  by  the  urethra  as  soon 
almost  as  it  is  brought  in  by  the  uterers,  no  urine  is 
retained.  If  a  catheter  is  introduced  the  viscus  will 
be  found  to  be  empty,  or  nearly  so.  In  these  cases 
the  urine  continues  acid,  often  markedly  loaded  with 
uric  acid,  as  Ollivier  has  remarked.  In  the  other  form 
of  paralysis  there  is  partial  or  complete  retention.  The 
bladder  falls  into  a  state  of  atony,  becomes  dilated  by 
the  gradual  accumulation  of  the  urine  which  it  is  unable 
to  expel.  At  last  the  overflow  will  dribble  away  as  in 
ordinary  senile  atony  of  the  bladder.  In  these  cases 
there  is  a  great  tendency  to  alkalinity,  owing  to  the 
development  of  sub-acute  cystitis.  It  is  the  kind  of 
paralysis  that  is  most  common  in  the  more  severe  forms 
of  spinal  concussion  and  lesion.  It  would  appear  as  if 
in  these  cases  the  sensibility  of  the  bladder  was  lost, 
and  that  the  stimulus  of  the  accumulated  urine  was 
not  felt  in  a  sufficient  degree  to  develop  the  requisite 
reflex  expulsive  action. 

The  condition  of  the  bowels  closely  resembles  that 
of  the  bladder.  In  some  cases  there  is  relaxation  of 
the  sphincter  ani,  and  the  peristaltic  action  being  free,  a 


68  ON   CONCUSSION   OF  THE   SPINE. 

kind  of  spurious  diarrhoea  sets  in.  But  more  commonly 
in  cases  of  spinal  concussion  the  bowels  are  confined, 
owing  apparently  to  a  want  of  extrusive  action  in  the 
abdominal  muscles  as  well  as  to  impaired  peristaltic 
motion. 

Priapism  does  not  occur  in  concussion  as  it  does 
after  laceration  and  irritation  of  the  cord.  Indeed,  as 
a  rule,  the  genitals  are  very  flaccid,  and  the  venereal 
desire  as  well  as  power  is  lost. 

6.  The  temperature  of  the  body  generally,  but  more 
especially  of  the  extremities,  is  found  to  undergo  impor- 
tant modifications  in  injuries  of  the  spinal  cord.  It 
may  fall  below  or  rise  materially  above  the  normal 
point.  The  fall  or  rise  will  depend  upon  the  nature  of 
the  injury  as  well  as  on  the  part  of  the  spine  that  is  the 
seat  of  injury. 

In  spinal  concussion  there  is  as  a  rule  a  fall  of  tem- 
perature. In  laceration  or  crush  of  the  spinal  cord, 
consequent  on  fracture  of  a  vertebra,  there  is  often  a 
rise — the  more  so  if  the  cervical  spine  is  the  seat  of 
injury. 

The  temperature  in  cases  of  spinal  concussion  may 
fall  and  remain  for  many  weeks  or  months  below  nor- 
mal point.  It  is  not  very  easy  to  arrive  at  a  true  esti- 
mate of  low  temperatures.  The  high  are  positive  facts 
and  easily  observed,  but  the  low  are  rather  of  a  nega- 
tive character,  and  may  easily  escape  detection  or  may 
not  so  readily  be  determined  or  may  be  ascribed  to 
imperfect  or  faulty  observation  rather  than  to  actual 
existence.  I  have  however  seen  unequivocal  instances 
of  continued  low  temperatures  of  the  body  in  the  mouth 
and  axilla,  in  cases  of  spinal  concussion,  as  low  as  92° 
to  93°  F.  and  continuing  for  many  months  from  2°  to 
3°  F.  below  normal.  But  the  temperature  may  fall 
lovv^er  than  this  in  a  more  serious  injury  of  the  cord. 
Thus  Dr.  Nieden  relates  a  case*  in  which  after  disloca- 
tion of  the  first  dorsal  vertebra,  with  crush  of  the  cord  at 
the  seat  of  injury  and  much  meningeal  ecchymosis,  the 
temperature  fell  to  81°  F.,  from  which  it  progressively 


*  Clinical  Society's  Transactions,  1873. 


CONCUSSION   OF  SPINE   FROM  VIOLENCE.  69 

sank,   the    patient   dying  on   the   eleventh   day  with   a 
temperature  of  80°. 6  F. 

More  commonly  the  low  temperature  is  confined  to 
the  extremities,  especially  the  feet,  which  are  sensibly 
colder  than  other  parts  of  the  body.  Often  the  feet  are 
as  low  as  from  80°  to  85°  F.,  and  will  remain  so  for  very 
long  periods  of  time. 

The  two  feet  and  even  the  two  axillse,  although  both 
below  normal  point  as  to  temperature  may  be  equally 
so  by  several  degrees,  2^,  3°,  or  more.  A  continuous 
depression  of  temperature  on  one  side  of  the  body  may 
be  the  fore-runner  of  hemiplegia,  and  any  way  is  often 
connected  with  a  loss  of  innervation  that  amounts  to 
loss  of  power,  though  not  perhaps  to  actual  paralysis, 
as  evidenced  by  diminished  power  in  the  grasp  of  the 
hand  or  impaired  motility  of  the  foot. 

I  have  never  met  with  a  high  temperature  in  cases 
of  spinal  concussion  unless  occasioned  by  inflammatory 
complications  of  an  obvious  character.  It  is  well  known 
however  that  in  primary  injury  of  the  cord  in  the  cervical 
region  the  temperature  of  the  body  will  often  rise  very 
considerably  shortly  before  death.  Brodie,  who  first 
observed  this  fact,  noticed  that  in  one  case  it  rose 
to  111°  F.  And  since  his  time  this  observation  has 
been  verified  by  most  surgeons.  The  highest  tempera- 
tures noted  in  these  cases  however  have  been  under  112° 
F.  and  a  persistently  higher  temperature  was  scai-cely 
supposed  to  be  consistent  with  the  continuance  of  life, 
until  the  case  recently  related  to  the  Clinical  Society 
by  Mr.  J.  W.  Teale*  with  so  much  circumstantiality 
of  detail  and  so  much  accuracy  of  observation  as  to 
leave  no  doubt  as  to  the  complete  trustworthiness  of 
the  facts,  astounding  as  they  are,  and  subversive  of  all 
previous  experience  on  the  subject.  In  this  remarkable 
case  the  patient,  a  young  lady,  sustained  a  severe,  but 
obscure  injury  of  the  spine  by  her  horse  falling  in 
taking  a  gate  and  rolling  upon  her.  She  recovered 
after  a  lengthened  illness,  during  sixty  days  of  which 
the  temperature  ranged  from  105°  to  120°  and  even 
122°  F. 

*  Clinical  Society's  Transactions,  Feb.  28,  1875. 


70  ON  CONCUSSION   OF  THE   SPINE. 

It  is  not  my  intention  at  present  to  enter  into  a 
description  of  the  symptoms  that  result  from  the  sec- 
ondaiy  and  more  remote  effects  of  blows  on  the  spine, 
and  of  concussion  of  the  cord.  All  this  I  shall  reserve 
for  a  later  lecture.  It  will  suffice  for  me  to  say  that 
these  symptoms  are  usually  occasioned  by  the  develop- 
ment of  inflammation  of  the  meninges  and  of  the  cord 
itself.  They  consist  of  pain  in  some  part  or  parts  of 
the  spine,  greatly  increased  by  pressure  and  motion, 
associated  with  reflex  rigidity  of  the  muscles  of  the 
back,  the  patient  moving  the  vertebral  column  as  a 
whole.  The  pain  is  greatly  increased  by  all  movements, 
but  especially  by  those  of  rotation. 

Pain  frequently  extends  down  the  limbs  or  round  the 
body,  giving  the  sensation  of  a  cord  tied  tightly. 

If  the  case  go  on  to  the  development  of  acute  in- 
flammatory action  in  the  cord  and  its  membranes, 
cramps  and  spasms  of  a  serious  character  occur — at 
first,  usually  of  the  nature  of  trismus — then  general 
spasms  of  the  body  and  limbs  of  a  tetanic  character, 
often  followed  by  speedy  death  from  the  exhaustion 
produced  by  the  repetition  of  these  violent  convulsive 
movements. 

If  the  inflammatory  action  assume  a  chronic  and  sub- 
acute character,  permanent  alterations  in  the  structure 
of  the  cord  will  ensue,  which  will  lead  to  much  local 
pain  and  tenderness  in  the  spine  itself,  to  neuralgic 
cramps  in  the  limbs,  and  eventually  to  paralytic  affec- 
tions of  an  incurable  nature,  usually  confined  to  the 
lower  extremities,  with  symptoms  indicative  of  the  ex- 
tension of  the  inflammatory  mischief  to  the  cerebral 
meninges  or  to  the  brain,  and  associated  with  great  and 
radical  derangement  of  the  general  health. 

Concussion  of  the  spine  from  a  direct  and  severe 
injury  of  the  back  may  terminate  in  one  of  four  ways : 
— I.  In  complete  recovery  after  a  longer  or  shorter 
time ;  2.  In  incomplete  recovery ;  3.  In  permanent  dis- 
ease of  the  cord  and  its  mem.branes ;  and,  4.  In  death. 

The  probability  of  the  termination  in  recovery  does 
not  depend  so  much  on  the  actual  severity  of  the  im- 
mediate symptoms  that  may  have  been   occasioned    by 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  ^1 

the  accident  as  on  their  persistence.  If  they  continue 
beyond  a  certain  time,  changes  will  take  place  in  the 
cord  and  its  membranes  which  are  incompatible  with 
the  proper  exercise  of  their  functions. 

Concussion  of  the  spinal  cord  from  a  severe  and 
direct  blow  upon  the  back  may  prove  fatal  at  very  dif- 
ferent periods  after  the  injury.  The  time  at  which  death 
occurs  will  depend  partly  on  the  situation  of  the  blow, 
but  in  a  great  measure  on  the  lesions  to  which  it  has 
given  rise. 

Concussion  of  the  spinal  cord  may,  and  often  has, 
proved  fatal  by  the  sudden  induction  of  paralysis, 
though  no  lesion  suf^cient  to  explain  the  fatal  termina- 
tion of  the  case  be  found  after  death. 

In  this  respect  it  resembles  concussion  of  the  brain. 
But  it  is  probable  that  it  might  be  found  in  a  fatal 
spinal  concussion,  that  the  nervous  substance  is  widely 
and  profusely  studded  with  disseminated  punctiform 
blood  extravasations,  as  I  have  observed  in  fatal 
cerebral  concussion. 

Abercrombie  says,  "  Concussion  of  the  cord  may  be 
speedily  fatal  without  producing  any  morbid  appear- 
ance that  can  be  detected  on  dissection."  And  he  refers 
to  the  case  related  by  Boyer,  and  to  four  cases  recorded 
by  Frank  in  confirmation  of  this  remark. 

But  in  other  cases  the  fatal  result  may  have  been 
occasioned  by  direct  and  demonstrable  lesion  of  the 
cord. 

There  appears  to  be  four  forms  of  lesion  that  will 
lead  to  a  fatal  result  in  cases  of  spinal  concussion. 

1.  Haemorrhage  within  the  spinal  canal. 

2.  Laceration  of  the  membranes  of  the  cord,  and 
extrusion  of  the  medullary  substance  into  the  spinal 
canal. 

3.  Extravasation  into  the  substance  of  the  cord. 

4.  Disintegration  and  perhaps  inflammatory  soften- 
ing of  the  cord. 

I.  Haemorrhage  within  the  spinal  canal  may  occur: 
1st.  Between  the  vertebrae  and  the  dura  mater. 
2nd.  Between  the  membranes  and  the  cord. 
3rd.  In  both  situations. 


72  ON  CONCUSSION   OF  THE   SPINE. 

In  these  respects  intravertebral  extravasations  resem- 
ble closely  those  that  occur  as  the  result  of  injury 
within  the  cranium.  The  three  following  cases  are 
illustrations  of  these  three  forms  of  haemorachis. 

Sir  A.  Cooper  mentions  one  case,  to  which  I  shall 
have  occasion  hereafter  to  refer,  in  which,  in  conse- 
quence of  a  strain  of  the  neck  in  a  boy  aged  twelve, 
symptoms  of  paralysis  slowly  supervened,  which  proved 
fatal  at  the  end  of  a  twelve  month. 

On  examination  after  death,  "  the  theca  vertebralis 
was  found  overflowing  with  blood,  which  was  effused 
between  it  and  the  inclosing  canals  of  bone."  This 
extravasation  extended  from  the  first  cervical  to  the  first 
dorsal  vertebra. 

MuUer"^  relates  the  case  of  a  corporal  of  Cuirassiers 
who  fell  from  a  hay-loft  on  to  his  back,  striking  it 
against  a  log  of  wood.  He  was  found  to  be  completely 
paralyzed  in  his  lower  limbs,  but  preserved  his  con- 
sciousness. He  died  on  the  second  day.  On  examina- 
tion it  was  found  that  there  was  a  large  quantity  of 
blood  extravasated  between  the  spinal  cord  and  its 
membranes.  This  extravasation  extended  from  the 
sixth  cervical  to  the  ninth  dorsal  vertebra. 

Ollivierf  relates  the  case  of  a  woman,  aged  49,  who 
threw  herself  out  of  a  window  in  the  fourth  story, 
alighting  on  her  back.  There  was  a  complete  paralysis 
of  the  lower  limbs,  with  incontinence  of  urine.  Her 
mental  faculties  were  unimpaired.  She  died  on  the 
third  day  after  the  injury,  and  on  examination  it  was 
found  that  there  was  a  fracture,  but  without  any  dis- 
placement of  the  tenth  dorsal  vertebra ;  at  this  spot 
blood  was  extravasated  between  the  vertebra  and  the 
dura  mater,  and  also  into  the  sabarachnoid  cellular 
tissue. 

2.  Death  may  occur — in  that  form  of  severe  concus- 
sion which  we  are  at  present  considering — from  lacera- 
tion of  the  pia  mater,  and  consequent  hernia  of  the 
cord.  Of  this  form  of  fatal  result,  Ollivier  records  one 
case,  that  of  a  man,  aged  46,  who  had  fallen  heavily  on 

*Bu//.  des  Sc.  Medicales,  1826.  fVol.  i,  p.  492. 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  /3 

his  back,  striking  the  spine  in  the  middle  of  the  dorsal 
region.  He  had  paraplegia,  loss  of  power  in  the 
sphincters,  violent  pain  in  the  spine  at  the  seat  of 
injury,  and  much  constitutional  disturbance.  He  died 
on  the  seventeenth  day.  On  examination  after  death 
it  was  found  that  the  pia  mater  of  the  cord  had  been 
ruptured  at  two  places  opposite  to  the  seat  of  injury, 
giving  exit  to  the  medullary  substance  in  two  patches, 
each  about  the  size  of  a  halfpenny,  about  two  or  three 
lines  in  thickness,  and  of  a  reddish  color.  These  pro- 
trusions had  passed  out  of  two  longitudinal  slits  in 
the  meninges  of  the  cord,  each  about  one  inch  in 
length,  situated  at  the  medial  and  posterior  part,  and 
opposite  to  the  fourth  and  fifth  dorsal  vertebrae.  At 
the  points  opposite  to  these  hernial  protrusions,  the 
spinal  cord  was  much  contracted,  having  lost  a  great 
part  of  its  substance  ;  but  it  preserved  its  normal  con- 
sistence. The  dura  mater  contained  a  large  quantity 
of  bloody  serum. 

3.  Extravasation  into  the  substance  of  the  spinal 
cord  is  undoubtedly  a  rare  lesion,  but  that  it  may  occur 
as  the  result  of  injury  there  can  be  no  doubt  In  many 
of  the  cases  in  which  sensation  is  more  affected  than 
motion,  or  in  which  the  principal  lesion  consists  in  a 
modification  of  sensation,  coming  on  immediately  after 
the  receipt  of  a  blow  on  the  back,  there  may  be  reason 
to  suspect  laceration  of  the  grey  matter  with  extrava- 
sation of  blood  into  it.  Hammond^  mentions  two  cases 
in  which  incurable  paraplegia  followed  supposed  spinal 
haemorrhage.  Speedy  death,  however,  most  usually 
occurs  as  a  consequence  of  such  an  injury. 

4.  The  last  condition  of  the  cord  that  leads  to  a  fatal 
termination  in  these  cases  of  concussion  arising  frorn 
direct  and  severe  injury  is  inflammation,  with,  perhaps, 
suppuration  of  the  meninges,  followed  by  inflammatory 
softening  and  disintegration  of  its  substance.  This 
is,  doubtless,  of  an  acute  and  probably  inflammatory 
character.  The  following  cases  will  illustrate  this 
morbid  state. 


*  "  Diseases  of  the  Nervous  System,"  New  York,  1873,  p.  440. 


74  ON   CONCUSSION   OF  THE   SPINE. 

OUivier  relates  the  case  of  a  man,  aged  28,  who  fell 
from  the  second  story  of  a  house,  striking  himself 
violently  on  his  back,  left  hip,  and  thigh.  His  lower 
extremities  became  paralyzed  completely,  as  far  as 
motion  was  concerned  ;  incompletely,  as  to  sensation. 
The  sphincters  were  paralyzed.  He  died  on  the 
thirtieth  day  after  the  accident.  On  examination  after 
death,  it  was  found  that  the  spinous  process  of  the 
fourth  cervical  vertebra  was  detached  but  not  displaced, 
and  the  twelfth  dorsal  vertebra  was  broken  across  but 
not  displaced.  The  spinal  cord  was  healthy  in  all  parts 
except  opposite  this  point,  where  it  was  soft,  dififluent, 
of  a  yellowish-grey  color,  and  injected  with  capillary 
vessels. 

A  remarkable  case  is  recorded  by  Sir  C.  Bell.*  It 
is  that  of  a  wagoner  who  was  pitched  off  the  shafts 
of  his  cart  on  to  the  ground,  falling  on  his  neck  and 
shoulders.  At  this  part  there  was  evidence  of  bruising. 
He  could  not  stand,  and  dragged  his  legs.  He  lay 
for  nearly  a  week  without  complaint,  and  had  during 
this  time  no  sign  of  paralysis.  But  on  the  eighth  day 
he  was  suddenly  seized  with  convulsions  over  the 
whole  of  the  body — which  were  relieved  by  bleeding. 
He  became  maniacal,  but  in  the  course  of  twelve  hours 
the  convulsions  ceased,  and  he  was  again  tractable.  On 
the  third  day  after  this  attack  he  complained  of  diffi- 
culty in  using  his  arm,  and  on  the  fifth  day  he  had  total 
palsy  of  the  lower  extremities,  regaining  the  use  of  his 
arm.  He  died  about  a  week  after  this.  On  examina- 
tion after  death,  it  was  found  that  a  considerable  space 
existed  between  the  last  cervical  and  the  first  dorsal 
vertebrae.  The  intervertebral  substance  was  completely 
destroyed,  and  an  immense  quantity  of  pus  surrounded 
the  bones.  This  purulent  collection  had  dropped  down 
:ihrough  the  whole  length  of  the  sheath  of  the  cord  to 
the  corda  equina. 

The  following  case  offers  a  remarkable  resemblance 
to  the  preceding  one — being  attended  by  nearly'iden- 
tical  post-mortem  appearances  following  the  same  kind 
of  injury. 

*  "Op.  Cit.,"  p.  145. 


CONCUSSION   OF   SPINE   FROM   VIOLENCE.  75 

Dr.  Mayes,'^'  of  Sumter  District,  South  Carolina,  re- 
lates the  case  of  a  negro  who,  while  raccoon-hunting,  fell 
a  height  of  fifteen  feet  from  a  tree,  striking  his  back  at 
the  lower  cervical  and  upper  dorsal  regions  against  the 
ground.  He  instantly  became  completely  paraplegic, 
and  died  on  the  lOth  day.  On  examination  seven 
hours  after  death,  it  was  found  that  the  fifth  and  sixth 
cervical  vertebrae  were  separated  from  each  other  pos- 
teriorly, but  not  fractured  or  dislocated.  Here  there 
was  manifest  injury  to  the  medulla.  As  soon  as  the 
muscular  coverings  of  the  spine  were  cut  through,  the 
softened  and  disintegrated  medulla  gushed  out  "  similar 
to  the  escape  of  matter  from  an  abscess  when  opened 
by  the  lancet.  The  medulla  spinalis  was  evidently  at 
this  point  in  a  state  of  decomposition." 

In  this  case  it  is  evident  that  not  only  the  meninges 
of  the  cord,  but  the  ligamenta  subflava,  were  torn 
through,  and  the  arches  of  the  vertebrae  separated  to 
such  an  extent  that  the  softened  and  disorganized 
medulla  found  a  ready  exit  through  the  gap  thus  made 
at  the  posterior  part  of  the  spinal  column. 

It  is  a  point  of  much  practical  moment  to  observe 
that  in  this,  as  in  several  other  of  the  cases  of  so-called 
"  concussion  of  the  spine,"  there  is,  in  addition  to  the 
lesion  of  the  cord,  some  serious  injury  inflicted  on  the 
ligamentous  and  bony  structures  that  enter  into  the 
composition  of  the  vertebral  column,  which,  however, 
must  be  considered  as  an  accidental  complication,  as  it 
does  not  occasion,  or  even  seriously  aggravate,  the  mis- 
chief done  to  the  medulla  itself.  Thus  the  ligaments, 
as  in  the  case  just  related,  may  be  torn  through  so  as 
to  allow  of  partial  separation  of  contiguous  vertebrae, 
or,  as  in  Cases  14  and  15,  a  vertebra  may  be  fractured — 
but  without  any  displacement  of  the  broken  fragments, 
or  other  sign  by  which  it  is  possible  during  life  to  deter- 
mine the  exact  amount  of  injury  that  has  been  inflicted 
on  the  parts  external  to  the  cord.  In  this  respect 
injuries  of  the  spine  again  closely  resemble  those  of  the 
head — their  chief   importance   depending,  not   on  the 

*  Southern  Medical  and  Surgical  Journal,  1847. 


76  ON   CONCUSSION   OF   THE   SriNE. 

amount  of  injury  to  the  containing,  but  on  that  inflicted 
upon  the  contained  parts.  In  the  spine,  just  as  in  the 
head,  it  will  sometimes  be  found  after  death  from 
what  it  appears  to  be,  and  in  reality  is,  simple  injury  of 
the  nervous  centres,  that  the  vertebral  column  in  the 
one  case,  and  the  skull  in  the  other,  have  suffered  an 
amount  of  injury  that  was  unsuspected  during  life  ;  and 
which,  though  it  may  not  in  any  way  have  determined 
the  fatality  of  the  result,  yet  affords  conclusive  evidence 
of  the  violence  to  which  the  parts  have  been  subjected, 
and  the  intensity  of  the  disorganizing  shock  that  they 
have  suffered. 

There  is,  however,  this  very  essential  difference 
between  the  spine  and  the  head  in  these  respects — that 
a  simple  fracture  of  the  cranium  may  be  of  no  moment 
except  so  far  as  the  violence  that  has  occasioned  it  may 
have  injured  the  brain.  Whilst  in  the  spine  the  case 
is  not  parallel ;  for  as  the  vertebral  column  is  the  centre 
of  support  to  the  body,  its  action  in  this  respect  will 
be  lost  when  it  is  broken  ;  even  though  the  spinal  cord 
may  not  have  been  injured  by  the  edges  of  the  frac- 
tured vertebrae,  but  only  violently  and  possibly  fatally 
concussed  by  the  same  force  that  broke  the  spine  itself. 

Boyer  had  long  since  noticed  the  very  interesting 
practical  fact,  that  when  the  interspinous  ligaments 
were  ruptured  in  consequence  of  forcible  flexion  of  the 
spine  forwards,  no  fatal  consequences  usually  ensue,  the 
integrity  of  the  parts  being  restored  by  rest.  But  that 
when  the  ligamenta  subflavia  are  torn  through,  and  the 
arches  separated,  paraplegia  and  death  ensue.  This  he 
attributes  to  stretching  of  the  spinal  cord.  Sir  C.  Bell, 
however,  with  great  acuteness,  has  pointed  out  the 
error  of  this  explanation,  and  states  that  "  it  is  the  pro- 
gress of  inflammation  to  the  spinal  marrow,  and  not 
the  pressure  or  extension  of  it,  which  makes  these 
cases  of  subluxation  and  breach  of  the  tube  fatal." 
There  can  be  no  doubt  that  this  explanation  is  the  cor- 
rect one,  and  that  when  once  the  spinal  canal  is  forcibly 
torn  open,  fatal  inflammation  will  spread  to  the  men- 
inges and  to  the  medulla  itself. 

The   secondary  consequences   of  concussion   of  the 


CONCUSSION   OF   SPINE   I- ROM    VIOLENCE.  77 

Spine,  more  especially  when  following  slight  injuries  of 
the  spine,  will  be  fully  detailed  in  subsequent  lectures. 
I  may,  however,  describe  here  perhaps  the  most  marked 
case  on  record   of  inflammatory  softening  of  the  cord 
consequent  upon  concussion  of  it,  unattended  with  any 
injury  to  the  osseous  or  ligamentous  structures  of  the 
spine.     It  occurred   in  the  practice  of   Dr.  Hunter,  of 
Edinburgh,  and  is  related  by  Abercrombie.    It  was  that 
of  a  man  thirty-six  years  of  age,  who  fell  from  the  top 
of  a  wagon,  a  height  of  ten  feet,  into  a  pile  of  small 
stones,  striking  his  back  between  the  shoulders.     He 
was  immediately  rendered  paraplegic.     When  admitted 
into  the  Edinburgh  Infirmary  at  the  end  of  a  month  he 
was  greatly  emaciated  ;  there  was  paralysis  of  motion, 
but  not  of  sensation,  in  the  lower  extremities,  retention 
of  urine,  involuntary  lixuid  motions,  deep-seated  pain 
on  pressure  in  the  region  of  the  third,  fourth,  and  fifth 
dorsal  vertebrse.     Three   days  after  admission   tetanic 
symptoms  came  on,  then  more  general  spasms  of  the 
limbs  and  body,  of  which  he  died  in  forty-eight  hours. 
On  examination  after  death  there  was  no  injury  found 
to  the  spine  itself.     There  was  a  high  degree  of  vascu- 
larity of  the  pia  mater  of  the  cord  in  the  dorsal  region. 
There  was  most  extensive  softening  of  the  body  of  the 
cord,  affecting  chiefly  the  anterior  columns.     "  These 
were  most  remarkably  softened  throughout  almost  the 
whole  course  of  the  cord  ;  in  many  places  entirely  dif- 
fluent ;    the   posterior  columns  were    also   softened   in 
many    places,    though    in    a    much    smaller   degree." 
This   case    epitomises    so    succinctly   and    clearly   the 
symptoms    and    after-death    appearances    occurring   in 
cases   of    inflammatory  softening   after  uncomplicated 
concussion  of  the  cord  from  severe  and  direct  violence, 
that  it  needs  neither  comment  nor  addition. 

The  consideration  of  these  subjects  in  connection 
with  concussion  of  the  spine  as  the  result  of  severe  and 
direct  violence,  will  pave  the  way  for  what  I  shall  have 
to  say  in  the  next  lecture  about  concussion  of  the  spine 
as  the  result  of  slight,  indirect,  and  less  obvious  injuries. 


LECTURE  IV. 

ON   CONCUSSION   OF   THE   SPINE  FROM   SLIGHT  OR 
INDIRECT    INJURY. 

In  the  last  lecture  I  directed  your  attention  to  the 
symptoms,  effects,  and  pathological  conditions  pre- 
sented by  cases  of  concussion  of  the  spine,  proceeding 
from  the  infliction  of  severe  injury  directly  upon  the 
vertebral  column  so  as  immediately  and  injuriously  to 
influence  the  organization  and  action  of  the  delicate 
nervous  structures  included  within  it. 

My  object  in  the  present  lecture  is  to  direct  your 
attention  to  a  class  of  cases  in  which  the  injury  inflicted 
upon  the  back  is  either  very  slight  in  degree,  or  in 
which  the  blow,  if  more  severe,  has  fallen  upon  some 
other  part  of  the  body  than  the  spine,  and  in  which, 
consequently,  its  influence  upon  the  cord  has  been  of 
a  less  direct  and  often  of  a  less  instantaneous  char- 
acter. 

Nothing  is  more  common  than  that  the  symptoms  of 
spinal  mischief  do  not  develop  for  several  days  after 
heavy  falls  on  the  back.  The  following  is  an  illustra- 
tion of  this  fact. 

Case  17. — E.  W.,  aged  39,  consulted  me  on  June  10, 
1872,  for  severe  pain  in  the  lumbar  spine,  and  inability 
to  walk  and  ride.  The  history  he  gave  was  this :  that 
four  months  previously,  on  February  28,  1872,  he  had 
been  thrown  in  hunting  by  his  horse  falling.  He 
turned  completely  over  and  landed  on  his  back.  He 
got  up  and  went  on  as  if  nothing  had  happened.  It 
was  not  till  a  week  afterwards  that  whilst  quietly  trot- 
ting he  was  seized  with  pain  in  the  small  of  his  back. 
He  was  obliged  to  go  home  and  keep  his  bed  for  eight 
days,  since  which  time  he  had  not  been  able  to  ride, 
and  had  suffered  the  usual  symptoms  of  spinal  concus- 
sion. 

Cases  such  as  this  are  extremely  interesting  to  the 
surgeon,  for  not  only  is  the  relation  between  the  injury 
sustained  and  the  symptoms  developed   less   obvious 

78 


INJURY   OF  THE   SPINE.  ^9 

than  in  the  former  class  of  cases,  but  in  consequence  of 
the  length  of  time  that  often  intervenes  between  the 
occurrence  of  the  accident  and  the  production  of  the 
more  serious  symptoms,  it  becomes  no  easy  matter  to 
connect  the  two  in  the  relation  of  cause  and  effect. 

Symptoms  indicative  of  and  arising  from  concussion 
of  the  spine  have  of  late  years  been  very  often  met  with 
in  surgical  practice,  in  consequence  of  the  frequency  of 
injuries  sustained  by  passengers  in  railway  collisions, 
and  they  have  been  very  forcibly  brought  under  the 
observation  of  surgeons  in  consequence  of  their  having 
become  fertile  sources  of  litigation  ;  actions  for  damages 
for  injuries  alleged  to  have  been  sustained  in  railway 
collisions  having  become  of  such  frequent  occurrence 
in  our  courts  of  law  as  now  to  constitute  a  very  impor- 
tant part  of  medico-legal  enquiry. 

The  symptoms  arising  from  these  accidents  have 
been  very  variously  interpreted  by  surgeons,  some 
ignoring  them  entirely,  believing  that  they  exist  only 
in  the  imagination  of  the  patient,  or,  if  they  do  admit 
their  existence,  they  attribute  them  to  other  conditions 
of  the  nervous  system  than  any  that  could  arise  from 
the  alleged  accident.  And  when  their  connection  with, 
and  dependence  upon,  an  injury  have  been  incontesta- 
bly  proved,  no  little  discrepancy  of  opinion  has  arisen 
as  to  the  ultimate  results  of  the  case,  the  permanence 
of  the  symptoms,  and  the  curability  or  not  of  the 
patient. 

It  will  be  my  endeavor  in  these  lectures  to  clear  up 
these  important  and  very  intricate  questions  ;  and  in 
doing  so  I  shall  direct  your  attention  particularly  to  the 
following  points : 

1.  The  effect  that  may  be  produced  on  the  spinal 
cord  by  slight  blows  when  inflicted  on  the  back  or  on  a 
distant  part  of  the  body. 

2.  The  length  of  time  that  may  intervene  between 
the  alleged  injury  and  the  development  of  the  symp- 
toms. 

3.  The  diagnosis  of  the  symptoms  of  "  concussion  of 
the  spine,"  from  those  arising  from  other  morbid  states 
of  the  nervous  system. 


8o  SLIGHT   OR   INDIRECT 

4.  The  grounds  on  which  to  form  a  prognosis  as  to 
the  probable  result. 

I  shall  illustrate  these  various  points  by  cases  selected 
from  my  notes,  not  only  of  persons  who  have  been 
injured  on  railways,  but  also  in  the  ordinary  accidents 
of  civil  life. 

But  before  we  proceed  further,  I  would  wish  particu- 
larly to  direct  your  attention  to  the  fact  that  there  is  in 
reality  no  difference  whatever  between  the  symptoms 
arising  from  a  concussion  of  the  spine  received  in  a 
railway  collision,  and  those  from  a  fall  or  odinary  acci- 
dent— except  perhaps  in  severity — and  that  therefore 
it  is  an  error  to  look  upon  a  certain  class  of  symptoms 
as  special  to  railway  accidents.  I  cannot,  indeed,  too 
strongly  impress  upon  you  the  fact  that  there  is  in  real- 
ity nothing  special  in  railway  injuries,  except  in  the 
severity  of  the  accident  by  which  they  are  occasioned. 
They  are  peculiar  in  their  severity,  not  different  in  their 
nature  from  injuries  received  in  the  other  accidents  of 
civil  life.  There  is  no  more  real  difference  between  that 
concussion  of  the  spine  which  results  from  a  railway 
collision  and  that  which  is  the  consequence  of  a  fall 
from  a  horse  or  a  scaffold,  than  there  is  between  a  com- 
pound and  comminuted  fracture  of  the  leg  occasioned 
by  a  grinding  of  a  railway  carriage  over  the  limb  and 
that  resulting  from  the  passage  of  the  wheel  of  a  street 
cab  across  it.  In  either  case  the  injury  arising  from  the 
railway  accident  will  be  essentially  of  the  same  nature 
as  that  which  is  otherwise  occasioned,  but  it  will  prob- 
ably be  infinitely  more  severe  and  destructive  in  its 
effects  when  it  affects  the  nervous  system,  owing  to  the 
greater  violence  by  which  it  has  been  occasioned,  and 
especially  because  it  is  not  the  result  of  one  single 
shock,  as  when  a  rider  is  thrown  from  his  horse,  or  a 
bricklayer  falls  from  a  scaffold,  but  is  due  to  a  succes- 
sion of  rapidly  repeated  concussions.  When  a  person 
is  thrown  to  and  fro  in  a  railway  collision,  he  is  dashed 
forwards  and  backwards,  mixed  up,  as  it  were,  and 
entangled  amongst  his  fellow  passengers,  alike  power- 
less to  resist  the  momentum  of  the  great  masses  in 
motion  around  him   or  to  extricate  himself  from  the 


INJURY   OF   THE   SPINE.  8l 

destructive  jarring  vibrations  of  the  splintering  car- 
riage. 

The  consideration  of  the  effects  that  may  be  pro- 
duced on  the  spinal  cord  by  slight  blows,  whether 
applied  to  the  back  or  to  a  distant  part  of  the  body,  is 
not  altogether  a  matter  of  modern  surgical  study  aris- 
ing from  the  prevalence  of  railway  accidents,  but  had, 
long  antecedent  to  the  introduction  of  modern  means 
of  locomotion,  arrested  the  attention  of  observant  prac- 
titioners. 

Abercrombie,  writing  in  1829  says,  that  chronic 
inflammations  of  the  cord  and  its  membranes,  "  may 
supervene  upon  very  slight  injuries  to  the  spine  ;"  and 
further  on  he  says,  '  every  injury  of  the  spine  should  be 
considered  as  deserving  of  minute  attention.  The 
more  immediate  effect  of  anxiety  in  such  cases  is 
inflammatory  action,  which  may  be  of  an  acute  or  chronic 
kind  ;  and  we  have  seen  that  it  may  advance  in  a  very 
insidious  manner  even  after  injuries  that  were  of  so 
slight  a  kind  that  they  attracted  at  the  time  little  or  no 
attention." 

Nothing  can  be  clearer  or  more  positive  than  this 
statement.  These  remarks  of  Abercrombie  are  con- 
firmed by  Ollivier,  by  Bell,  and  by  other  writers  on  such 
iujuries. 

The  following  cases  will  illustrate  this  point : 

The  two  first  are  cases  of  concussion  of  the  spine 
resulting  from  railway  accidents,  in  which  there  were 
at  the  time  slight  marks  of  external  injury.  The  others 
are  very  similar  cases  occurring  from  other  accidents 
than  those  received  on  railways. 

Case  18.  Nervous  Shock  from  Railway  Collision — 
Chronic  Meningitis  of  Cord  and  Base  of  Brain — Imper- 
fect Recovery  after  Nine  Years. — Mr.  R.,  35  years  of 
age,  a  farmer  and  miller,  of  veiy  active  habits,  accus- 
tomed to  field  sports,  and  much  engaged  in  business, 
habitually  in  the  enjoyment  of  good  health,  was  in  a 
railway  collision  that  took  place  on  November  4,  1864. 
He  received  a  blow  on  the  face  which  cut  his  upper  lip 
on  the  left  side,  and  was  much  and  severely  shaken. 
He  did  not  lose  consciousness,  and  was  able  shortly  to 
6 


82  SLIGHT    OR   INDIRECT 

proceed  on  his  journey.  On  leaving  the  station  to  pro- 
ceed to  his  own  home,  it  was  observed  by  a  friend  who 
drove  him  that  he  did  appear  to  recollect  the  road,  with 
which  he  was  familiar,  having  been  in  the  daily  habit  of 
driving  over  it  for  years. 

On  reaching  home,  feeling  bruised,  shaken,  and  con- 
fused, he  took  to  his  bed,  but  did  not  feel  sufficiently  ill 
to  seek  medical  advice  until  November  9,  five  days 
after  the  accident,  when  he  sent  to  Mr.  Yorke,  of  Staun- 
ton, who  continued  to  attend  him.  But  notwithstand- 
ing every  attention  from  that  gentleman,  he  progress- 
ively but  slowly  got  worse. 

I  saw  Mr.  R.  for  the  first  time  on  February  18,  1866, 
fifteen  months  after  the  occurrence  of  the  accident, 
when  I  found  him  in  the  following  state :  his  face  was" 
pallid,  much  lined,  indicative  of  habitual  suffering.  He 
looked  much  older  than  his  alleged  age  (36  years).  He 
was  sitting  with  his  back  to  the  light,  and  had  the 
Venetian  blinds  drawn  down  so  as  to  shade  the  room, 
the  light  being  peculiarly  distressing  to  him.  His  skin 
Avas  cool.  Tongue  slightly  furred,  appetite  moderate, 
digestion  impaired.  Pulse  104  to  106,  weak  and  com- 
pressible. I  understood  from  Mr.  Yorke  that  it  rarely 
fell  below  this,  and  often  rose  above  it.  He  had  not 
lost  flesh,  but  all  his  friends  said  that  he  was  quite  an 
altered  man. 

He  stated  that  since  the  accident  his  memory  had 
been  bad — that  he  could  not  recollect  numbers — did 
not  know  the  ages  of  his  children,  for  instance — he 
could  not  add  up  an  ordinary  s:im  correctly — he  would 
add  up  the  same  set  of  figures  if  transposed  differ- 
ently. Before  the  accident  he  was  considered  to  be  a 
particularly  good  judge  of  the  weights  of  beasts — 
since  its  occurrence  he  had  lost  all  power  of  forming  an 
opinion  on  this  point.  He  had  been  quite  unable  to 
transact  any  business  since  the  injury.  He  was 
troubled  with  frightful  dreams  and  often  started  and 
waked  up  in  terror  not  knowing  where  he  was.  Had 
become  irritable,  and  could  neither  bear  light  nor  noise. 
He  frowned  habitually,  so  as  to  exclude  the  light  from 
his  eyes.     He  complained    of    stars,    sparks,   flashes  of 


INJURY   OP    THE   SPINE.  83 

light,  and  colored  spectra  flaming  aud  flashing  before 
his  eyes.  He  could  not  read  for  more  than  two  or  three 
minutes  at  a  time,  the  letters  becoming  confused,  and 
the  effort  being  painful  to  bear.  On  examining  the 
state  of  the  eyes,  I  found  that  vision  was  good  in  the 
right  eye,  but  that  this  organ  was  over  sensitive  to  light. 
Vision  was  nearly  lost  in  the  left  eye,  so  much  so  that 
he  could  not  read  large  print  Vv'ith  it. 

His  hearing  was  over  sensitive  with  the  right  ear,  dull 
on  the  left  side.  He  conld  not  bear  noises  of  any  kind, 
more  particularly  if  sudden;  they  were  peculiarly  dis- 
tressing to  him.  Even  that  of  his  children  at  play 
annoyed  him. 

He  complained  of  a  numb  sensation  accompanied  by 
tingling,  burning  sensations  on  the  right  side,  in  the 
right  arm  and  leg,  more  particularly  in  the  little  and 
ring-fingers,  and  along  the  course  of  the  ulnar  nerve. 
The  rest  of  the  right  hand  felt  numb.  He  made  no 
complaint  of  the  left  arm  or  leg.  These  sensations 
were  worst  in  the  morning. 

He  could  not  stand  or  walk  without  the  support  of  a 
stick,  or  resting  his  hand  on  a  piece  of  furniture.  He 
could  stand  in  this  way  on  the  left  leg,  but  if  he 
attempted  to  do  so  on  the  right  foot  the  limb  immedi- 
ately bent,  and  sank  as  it  were  under  him.  His  gait 
was  very  peculiar.  He  separated  the  feet  so  as  to  make 
a  straddling  movement,  and  brought  one  foot  very 
slowly  before  the  other.  He  advanced  the  right  foot 
less  than  the  left,  and  did  not  raise  the  sole  as  far  from 
the  ground.  The  foot  seemed  to  come  down  too 
quickly.  He  did  not  drag  with  the  toes,  but  did  not 
raise  the  heel  sufHciently,  and  was  apt  to  catch  it  in 
walking  in  inequalities  on  the  ground.  Flexion  and 
extension  were  more  perfectly  and  rapidly  performed 
with  the  left  than  with  the  right  foot. 

The  attitude  of  hisbody  in  walking  was  very  peculiar; 
the  back  was  stiff,  the  head  fixed,  and  he  looked  straight 
forward  without  turning  it  to  the  one  side  or  the  other. 

He  had  great  difficulty  in  going  up  or  down  stairs, 
and  could  not  do  so  without  holding  on  by » the  balus- 
trade.    The  difficult)'  was  greatest  in  going  down  stairs, 


84  SLIGHT   OR   INDIRECT 

and  if  he  attempted  this  without  support  he  fell  or 
rolled  over  to  the  right  side. 

There  was  no  appreciable  difference  in  the  size  of  the 
two  legs,  but  the  right  felt  colder  than  the  left.  The 
patient  complained  of  the  coldness  of  both  legs  and 
feet. 

The  spine  had  lost  its  natural  flexibility,  so  that  the 
patient  kept  the  body  perfectly  straight,  fixed,  and 
immovable.  He  could  not  bend  the  body  in  any  direc- 
tion without  suffering  severe  pain.  This  was  com- 
plained of  equally  whether  the  patient  bent  forwards, 
backwards,  or  sideways.  It  was  most  severe  on  any 
attempt  being  made  to  twist  the  spine.  He  sat  in  a 
rigid  and  upright  attitude. 

There  was  considerable  pain  at  the  occipito-atloid 
articulation,  as  well  as  at  that  between  the  axis  and 
atlas.  If  an  attempt  was  made  to  bend  the  head  forci- 
bly for^vards,  or  to  rotate  it,  the  patient  suffered  so 
severely  that  he  had  to  desist.  When  directed  to  look 
round,  the  patient  turned  the  whole  body. 

Owing  to  the  rigidity  of  his  spine  he  could  not  stoop 
to  pick  anything  off  the  floor  without  going  down  on 
one  knee. 

On  examining  the  spine  by  pressure  and  percussion, 
three  tender  spots  were  found  ;  one  in  the  upper  cer- 
vical, another  in  the  middle  dorsal,  and  the  third  in  the 
lumbo-sacral  region.  There  w^as  pain  both  on  super- 
ficial and  on  deep  pressure  at  these  spots.  The  pain 
w^as  limited  to  the  spine,  and  did  not  extend  to  the 
muscular  structures  on  either  side  of  it. 

The  power  of  retaining  the  urine  was  very  much 
diminished.  He  passed  water  four  or  five  times  in  the 
night,  and  every  second  hour  during  the  day.  The 
urine  was  sub-acid. 

The  generative  power,  though  impaired,  was  not 
lost. 

A  remarkable  circumstance  had  been  noticed  in  this 
case  by  the  patient's  wife  and  his  friends.  It  was  that 
since  the  accident  he  was  unable  to  judge  correctly  of 
the  distance  of  objects  in  a  lateral  direction,  though  he 
appeared   to  be  able  to  do  so  when  looking  straight 


INJURY   OF  THE   SPINE.  85 

forward.  Thus,  when  driving  in  the  middle  of  a 
straight  road  he  always  imagined  that  the  carriage 
was  in  danger  of  running  into  the  ditch  or  hedge  on 
the  near  side. 

The  opinion  I  gave  w^as,  that  the  patient  had  sus- 
tained an  injury  of  the  spinal  cord,  and  that  the  base 
of  the  brain  Avas  also,  to  some  extent,  though  probably 
secondarily,  involved.  That  chronic  subacute  menin- 
gitis of  the  spine  and  base  of  the  cranium  had  taken 
place.  That  it  was  not  probable  that  the  patient 
would  ever  completely  recover,  and  that  it  was  even 
doubtful  w^iether,  as  the  disease  had  up  to  the  pres- 
ent time  been  progressive,  it  might  not  continue  so, 
and  terminate  in  irremediable  disorganization  of  the 
nervous  centres.  The  patient  Avas  seen  by  Sir  Charles 
Hastings  and  Mr.  Garden,  who  took  a  similarly 
unfavorable  view  of  his  present  state  and  probable 
future. 

An  action  was  brought  at  the  spring  assizes  at 
Worcester,  in  1866,  against  the  company  on  whose 
line  the  patient  had  been  injured.  No  surgical  evi- 
dence was  called  for  the  company,  the  statement  made 
by  the  plaintiff's  medical  advisers  being  accepted. 
Nine  years  after  the  accident,  in  1873,  I  had  an  oppor- 
tunity of  hearing  of  the  patient  from  his  medical 
attendant.  The  report  I  then  received  was  that  he 
had  never  recovered  his  bodily  health  and  strength, 
that  his  judgment  was  often  at  fault,  that  he  com- 
mitted extravagant  and  foolish  acts,  and  was  not  to  be 
relied  on  in  business  matters. 

Case  19. — Injury  to  Nervous  System  from  Railway 
Collision — No  Immediate  Effeets — Chronic  Meningitis — 
Imperfect  Recovery. — Mr.  J.,  43  years  of* age,  a  wine 
merchant,  healthy  and  of  active  business  habits,  was  in 
a  railway  collision  August  23,  1864.  He  was  suddenly 
dashed  forwards  and  then  rebounded  violently  back- 
wards. 

When  he  extricated  himself  from  the  ruins  of  the 
carriage  in  which  he  had  been  traveling  (a  third-class 
one),  he  believed  himself  to  be  unhurt — suffering  from 
no   immediate   effect  of  the   injur)-   lie  had  sustained. 


86  ST.ICriT   OR   INDIRECT 

He  assisted  his  fellow-passengers,  many  of  whoiti  were 
much  injured,  and  was  thus  actively  engaged  for  two 
hours. 

On  his  return  home  the  same  evening,  he  was  greatly 
excited  and  very  restless ;  he  felt  chilly,  and  his  arms 
and  legs  tingled.     He  could  not  sleep  that  night. 

On  the  follov/ing  day  he  felt  ill  and  shaken  ;  could 
not  attend  to  his  business,  and  was  lame  from  some 
slight  contusions  on  his  legs.  He  continued  much  in 
this  state  for  several  days,  and  was  seen  by  Mr.  Everett, 
of  Worcester  (to  whom  I  am  indebted  for  the  early 
history  of  this  case),  September  i,  eight  or  nine  days 
after  the  accident.  He  was  then  much  disturbed  in 
health  ;  his  pulse  was  feeble,  he  looked  anxious  and 
depressed  ;  he  complained  of  violent  pains  in  the  head, 
confusion  of  thought,  and  loud  noises  in  the  ears  and 
head;  He  also  complained,  but  slightly,  of  pain  in  the 
back. 

These  symptoms  continued  for  some  time  without 
improvement.  He  found  more  and  more  difficulty  in 
walking,  and  his  right  ankle  often  gave  way.  This 
appeared  to  Mr.  Everett  to  be  owing  to  some  spasmo- 
dic action  of  the  muscles  of  the  leg  rather  than  to  any 
weakness  of  the  joint  itself. 

He  now  began  to  show  more  serious  symptoms  in 
connection  with  the  nervous  system.  His  memory 
became  worse  and  his  confusion  of  ideas  greater ;  he 
often  called  people  and  things  by  wrong  names ; 
addressed  his  wife  as  "  Sir." 

The  pains  in  the  head  became  more  violent,  and 
assumed  a  paroxysmal  character.  There  was  acute 
sensibility  to  sound  in  the  right  ear,  deafness  of  the 
left.     The  vision  of  the  right  eye  was  rather  dim. 

This  was  his  condition  tv/elve  weeks  after  the  occur- 
rence of  the  accident.  The  symptoms,  though  pro- 
gressively assuming  a  more  and  more  serious  character, 
did  not  do  so  uninterruptedly,  but,  as  Mr.  Everett 
expresses  it,  were  ^' undulatory  " — sometimes  better, 
sometimes  worse ;  but  yet  at  the  expiration  of  any 
given  time  of  a  few  weeks'  duration,  decidedly  and 
persistently  worse  than  at  an  earlier  period. 


INJURY   OF   TPIE   SPINE.  8/ 

Three  months  after  the  accident  he  began  to  com- 
plain, for  the  first  time,  of  contractions  of  the  muscles 
of  the  right  arm  and  hand.  His  fingers  became  fixed, 
so  that  force  was  required  to  straighten  them.  Shortly 
afterwards  the  left  arm  became  similarly  affected. 
These  contractions  assumed  an  intermittent  and  spas- 
modic character,  and  occurred  several  times  daily. 

The  pain  in  the  back,  which  was  but  slightly  com- 
plained of  at  first,  now  became  more  and  more  severe. 
It  was  more  acute  from  the  sixth  to  the  tenth  dorsal 
vertebrae.  Spasms  of  the  diaphragm  now  came  on 
occasionally,  and  distressed  him  m.uch. 

His  gait  was  peculiar ;  he  seemed  to  be  uncertain 
where  to  set  his  feet,  and  he  kept  his  head  steadily  fixed. 

February  i,  1865,  five  months  after  the  accident,  he 
complained,  for  the  first  time,  of  pain  in  the  neck, 
greatly  increased  on  moving  the  head. 

During  the  whole  of  this  period  his  digestion  had 
been  fairly  good.  He  had  gained  flesh  since  the  acci- 
dent. There  had  been  no  loss  of  power  over  the 
sphincters,  and  his  urine  was  normal  and  acid. 

I  saw  this  patient,  in  consultation  with  Mr.  Garden 
and  Mr.  Everett,  of  Worcester,  on  March  8,  1865,  and 
found  that  the  symptoms  above  detailed  continued 
and  had  somewhat  increased  in  intensity  since  the  last 
report. 

He  suffered  from  loss  of  memory,  confusion  of 
thought  and  ideas,  utter  incapacity  for  business,  dis- 
turbed sleep,  pains  and  noises  in  the  head,  partial  deaf- 
ness of  the  left  ear,  morbid  sensibility  of  right,  irrita- 
bility of  the  eyes,  rendering  light  very  painful — though 
vision  had  become  imperfect  in  the  right  eye.  Numb- 
ness, tingling  sensation,  and  formication  in  the  right 
arm  and  leg,  were  the  most  prominent  subjective  symp- 
toms. 

He  walked  with  a  peculiar  unsteady  straddling  gait ; 
was  obliged  to  feel  with  his  right  foot  before  planting 
it  on  the  ground  ;  did  not  raise  the  heel,  but  carried 
the  foot  flat,  and  let  it  fall  suddenly,  instead  of  putting 
it  on  the  ground  in  the  usual  way ;  used  a  stick,  or 
supported  himself  by  the  furniture. 


88  SLIGHT   OR  INDIRECT 

He  could  stand  for  a  moment  on  the  left  leg,  but 
immediately  fell  over  if  he  attempted  to  do  so  on  the 
right. 

His  right  arm  and  hand  were  numb  ;  the  little  and 
ring  fingers  contracted.  He  could  not  pick  up  a  small 
object,  as  a  pin,  between  his  finger  and  thumb,  nor 
could  he  write  easily  or  legibly. 

The  spine  was  very  tender  at  three  points — in  the 
upper  cervical,  in  the  middle  dorsal,  and  in  the  loAver 
lumbar  regions.  There  was  constant  fixed  aching  pain 
in  the  spine  in  these  situations.  This  pain  was  greatly 
increased  on  pressure ;  it  was  limited  to  the  vertebral 
column,  and  did  not  extend  beyond  it. 

Movement  of  any  kind  greatly  increased  the  pain. 
If  the  head  was  raised  by  the  hands  and  bent  forward, 
or  rotated,  so  as  to  influence  the  occipito-atloid  and 
the  atlo-axiod  articulations,  the  patient  shrieked  with 
agony. 

He  could  not  bend  the  body  either  forwards,  back- 
Avards,  or  sideways,  the  pain  being  so  greatly  increased 
in  the  dorsal  and  lumbar  regions  by  these  movements. 
Consequently  he  could  not  stoop. 

The  spine  had  entirely  lost  its  normal  flexibility.  It 
was  perfectly  rigid,  moved  as  a  whole  as  if  made  of  one 
bone.  The  patient  could  neither  bend  nor  turn  his 
head.  Hence  he  could  not  look  on  the  ground  in  walk- 
ing to  see  where  to  place  his  feet ;  and  when  he  wished 
to  look  round,  he  had  to  turn  the  whole  body. 

The  pulse  was  feeble,  about  98.  Countenance  pale, 
anxious,  haggard.  Tongue  slightly  coated.  Digestive 
and  other  functions  well  performed.  Urine  clear  and 
acid. 

The  case  was  tried  at  the  Spring  Assizes  at  Worces- 
ter in  1865.  The  opinion  expressed  by  Mr.  Carden, 
Mr.  Everett,  and  myself  amounted  to  this,  that  the 
patient  was  suffering  from  concussion  of  the  spine, 
which  had  developed  irritation  or  chronic  inflammation 
of  the  cord  and  of  its  membranes,  and  that  his  recovery 
was  very  doubtful. 

In  May,  1866,  a  year  and  nine  months  after  the  acci- 
dent, he  was  still  an  invalid,  being  so  completely  shat- 


INJURY   OF   THE   SPINE.  89 

tei'ed  in  health  that  he  has  been  obHged  to  winter  in  the 
southwest  of  England,  and  was  quite  unequal  to  attend 
to  business  of  any  kind. 

In  1 87 1,  seven  years  after  the  accident,  Mr.  Walsh,  of 
Worcester,  informed  me  that  Mr.  J.  was  still  an  inva- 
lid; that  he  was  obliged  to  walk  with  two  sticks,  and  had 
not  recovered  the  sense  of  taste  ;  and  two  years  later 
than  this,  viz.;  in  1873,  Dr.  Weir,  of  East  Malvern, 
informed  me  that  Mr.  J.'s  condition  continued  unim- 
proved. 

Case  20. —  Carriage  Accident — Slozv  supervention  of 
Symptoms  of  Chronic  Cerebro-Spinal  Meningitis — 
Incurable. — The  following  case  illustrates  the  fact  that  a 
train  of  symptoms  of  a  most  persistent  nature,  closely 
resembling  those  detailed  in  the  preceding  cases,  may 
occur  from  other  causes  than  railway  accidents. 

Captain  N.,  aged  38,  consulted  me  on  October  27, 
1862.  He  looked  careworn,  pale,  lined,  and  at  least  ten 
years  older  than  his  real  age.  He  stated  that  in  Novem- 
ber, 1854 — eight  years  previously — he  had  been  thrown 
out  of  a  pony-chaise,  which  was  accidentally  upset.  He 
hurt  his  right  knee  and  bruised  the  right  arm,  but  sus- 
tained no  blow,  and  there  was  no  evidence  of  injury  on 
the  head  or  back.  He  was  much  bruised  and  shaken 
at  the  time,  but  did  not  suffer  any  serious  ill  effects  for 
several  months  after  the  accident,  although  during  the 
whole  of  this  period  he  felt  ailing,  and  was  in  some 
way  suffering  from  the  injury  he  had  sustained. 

About  six  months  after  the  accident  he  began  to  be 
troubled  with  the  following  train  of  symptoms,  which 
had  continued  ever  since : — Confusion  of  thought ; 
impairment  of  memory ;  giddiness,  especially  on  mov- 
ing the  head  suddenly ;  failing  sight ;  muscae  volitantes, 
and  sparks  and  flashes  of  light.  He  could  not  con- 
tinue to  read  beyond  a  few  minutes,  partly  because  the 
letters  ran  into  each  other,  partly  because  he  could  not 
concentrate  his  thoughts  so  as  to  fix  his  attention. 

He  now  began  to  suffer  from  a  feeling  of  numbness 
and  a  sensation  of  '  pins  and  needles '  in  both  hands, 
but  more  particularly  in  the  left,  and  chiefly  in  those 
parts  supplied  by  the  ulnar  nerve. 


90  SLIGHT   OR   INDIRECT 

He  com]3lained  of  similar  sensations  in  the  left  leg 
and  foot.  He  walked  with  difificulty,  and  with  the  legs 
somewhat  apart,  using  a  stick,  or  else  supporting  him- 
self by  holding  on  to  pieces  of  furniture  in  the  room 
as  he  passed  them.  He  could  stand  on  the  right  leg, 
but  the  left  one  immediately  gave  way  under  him.  He 
walked  with  great  difficulty  up  and  down  stairs,  and  was 
obliged  to  put  both  feet  on  the  same  step.  The  spine 
was  tender  on  pressure  and  percussion  in  the  lower  cer- 
vical region  and  between  the  shoulders.  The  spine  was 
stiff  and  he  could  not  bend  the  back  without  pain,  and 
could  not  stoop  without  falling  forward. 

He  had  irritability  of  the  bladder,  passing  water 
every  second  or  third  hour,  and  could  only  do  so  in  a 
sitting  posture.  He  had  completely  lost  all  sexual 
power  and  desire.  The  urine  was  slightly  acid.  These 
symptoms  had  continued  with  varying  intensity  since 
about  six  months  after  the  accident.  He  thought  they 
were  most  severe  about  a  year  after  they  began,  and 
had  somewhat  improved  since  then.  But  he  had  never 
been  free  from  them,  or  enjoyed  a  day's  health,  for 
the  last  seven  and  a  half  years,  and  did  not  expect  to 
do  so. 

This  case  closely  resembled,  in  all  its  general  features, 
and  in  many  of  its  details,  those  that  have  just  been 
related.  It  only  differed  in  the  symptoms  being  less 
intense,  as  would  naturally  be  expected,  from  the  acci- 
dent that  occasioned  them  being  less  severe  than  those 
which  occur  from  railway  collisions.  The  persistence 
of  the  symptoms  for  so  lengthened  a  period  as  nearly 
eight  years  was  significant  of  the  tenacity  and  long 
duration  of  the  pernicious  effects  of  these  insidious  and 
at  first  apparently  slight  injuries  to  the  nervous  system. 

But  the  prolonged  duration  of  the  most  serious  nerv- 
our  phenomena,  from  comparative  slight  injuries  to  the 
spine,  receives  additional  illustration  from  the  following 
case. 

Case  21. — Injury  of  Spine  in  infancy  Persistence  of 
Symptoms  to  Adnlt  Age. — -Miss  B.,  aged  26,  was  brought 
to  my  house,  April  1 1,  1866,  by  Sir  Duncan  Gibb.  She 
looked  moderately  healthy,  was  of  good  constitution, 


INJURY   OF  THE   SPINE.  9I 

with  no  discernible  hereditary  tendency  to  disease  of 
any  kind  and  was  not  anaemic.  The  digestive  and  uter- 
ine functions  were  well  performed.  She  had  had  no 
disease  except  that  from  which  she  was  then  suffering, 
no  convulsions  or  fits  in  childhood. 

When  about  eighteen  months  old,  she  fell  out  of  her 
cot  and  injured  her  cervical  spine.  From  that  time  she 
had  suffered  from^  a  continuous  and  remarkable  train  of 
nervous  phenomena  which  were  aggravated  about  the 
period  of  puberity,  and  which  were  still  further  increased 
at  the  age  of  17,  in  consequence  of  her  falling  over  a 
stile  backwards.  She  had  never  had  had  hysteria  in 
any  of  its  ordinary  forms,  or  paralysis,  epilepsy,  or  con- 
vulsive attacks  of  any  kind. 

On  examining  the  spine,  I  found  no  lateral  curvature 
and  the  body  was  well  formed.  There  was  a  distinct 
projection  backwards  of  the  spinous  processes  of  the 
fifth  and  sixth  cervical  vertebrse.  She  complained  of  a 
constant  pressure  and  pain  of  a  grating  or  grinding 
character  in  this  region,  as  if  the  bones  were  in  contact 
with  one  another.  There  was  no  evidence  of  abscess 
or  of  any  distinct  mischief  in  or  around  the  tender 
vertebrae,  and  nothing  was  to  be  observed  with  the 
laryngoscope  at  the  anterior  part  of  the  cervical  verte- 
brae or  in  the  pharynx.  From  the  projection  of  the  cer- 
vical vertebrae  a  peculiar  sense  of  uneasiness  spread 
itself  over  the  whole  of  the  body  and  limbs,  producing 
nervous  sensations  of  the  most  distressing  character. 
These  sensations,  which  consisted  of  tingling  and  pain- 
ful feelings,  prevented  her  sitting  still  or  lying  down 
qnietly  for  any  length  of  time.  She  was  better  when 
in  movement.  She  could  not  sleep  for  more  than  an 
hour  or  two  at  a  time,  and  was  conscious  of  her  suffer- 
ings through  her  sleep. 

Her  power  of  movement  had  never  been  impaired, 
the  distress  being  confined  to  sensation,  and  not  pro- 
ducing any  disturbance  of  motion. 

She  could  walk  well  under  certain  circumstances, 
could  stand,  and  in  fact  she  scarcely  ever  sat ;  but  she 
could  not  turn  suddenly  without  becoming  giddy  and 
afraid  of  falling. 


92      SLIGHT   OR   INDIRECT   INJURY   OF  THE   SPINE. 

She  could  walk  well  so  long  as  there  was  anything 
near  her.  Thus  she  could  walk  along  a  street  guided 
by  the  area  railings ;  but  when  she  came  to  an  open 
space,  as  a  square  or  crossing,  she  was  lost,  and  required 
to  be  guided  or  she  would  fall.  She  could  not  bear  the 
sensation  of  having  a  space  around  her,  and  would  fall 
unless  supported. 

She  had  unceasing  loud  noises  in  her  head,  which  she 
compared  to  "  gravel-stones  "  rolling  through  it.  They 
wxre  so  loud  that  she  fancied  that  other  people  must 
hear  them. 

Her  hearing  was  good. 

Her  sight  was  strong,  but  she  saw  the  circulation  of 
the  blood  in  her  eyes,  the  corpuscles  spinning  round  in 
convolutions,  and  often  colored.  There  was  no  per- 
version of  smell  or  taste.  The  hands  and  feet  were 
always  cold,  even  in  summer. 

She  had  been  from  first  to  last  under  the  care  of  at 
least  thirty  medical  men,  and  had  had  every  variety  of 
treatment  applied — even  a  seton  kept  open  in  the  neck 
and  the  clitoris  excised  ;  but  so  far  from  benefitting  she 
had  slowly  but  steadily  became  worse,  and  her  general 
health  was,  when  I  saw  her,  now  beginning  to  give 
way. 

This  lady,  who  was  remarkably  intelligent,  gave  a 
lengthened  and  minute  history  of  her  ailments,  of  which 
the  above  is  a  sketch.  She  referred  all  her  morbid  sen- 
sations to  the  seat  of  the  excurvation  in  the  cervical 
vertebrae.  At  this  point  there  had  evidently  existed 
disease  leading  to  organic  changes  to  which  the  remark- 
able train  of  general  phenomena  were  doubless  refer- 
rible.  If  I  were  to  hazard  an  opinion,  it  would  be  that 
some  thickening  of  the  meninges  of  the  cord  had  prob- 
ably taken  place,  the  effect  of  which  was  to  interfere 
with  the  sensory  portion  of  the  cord,  rather  than  with 
the  motor. 

Since  the  period  referred  to  above  this  patient  has 
married  and  has  had  children,  but  her  condition  of 
health,  so  far  as  the  nervous  system  is  concerned,  con- 
tinues unchanged. 


LECTURE  V. 

CONCUSSION  OF  THE  SPINE  FROM  GENERAL  SHOCK. 

There  is  another  class  of  cases  of  an  extremely  in- 
sidious and  protracted  character  to  which  I  wish  to 
direct  your  attention,  viz.,  those  cases  in  which  the 
patient  has  received  no  blow  or  injury  upon  the  head 
or  spine,  but  in  which  the  whole  system  has  received  a 
severe  shake  or  shock,  in  consequence  of  which  an  im- 
mediate lesion,  probably  of  a  molecular  character,  is 
sustained  by  the  spinal  cord,  and  disease  of  an  inflam- 
matory character,  or  of  a  disorganizing  nature  depend- 
ent on  modification  of  nutrition,  is  developed  in  it, 
the  inflammatory  action  eventually  creeping  up  to  the 
membranes  of  the  brain.  These  cases,  although  neces- 
sarily more  frequent  in  railway  than  in  other  injuries, 
do  occasionally  occur  as  a  consequence  of  ordinary 
accidents.  I  will  first  relate  a  case  of  this  kind,  and 
then  direct  your  attention  to  the  details  of  several  other 
instances  that  have  fallen  under  my  notice  of  similar 
phenomena  occurring  after  railway  accidents. 

Case  22. — Concussion  of  spine  iri  Hunting — No  Direct 
Injury  of  Back — Immediate  and  Severe  Symptoms  of 
Me?t  ingeal  Extravasation — Phlebitis — Pleuro-Pnemnonia 
— Complete  Recovery. — A  gentleman,  about  sixty  years 
of  age,  healthy,  of  active  habits,  and  much  given  to 
field  sports,  whilst  jumping  a  drop  fence  on  March  2, 
1872,  landed  on  the  pommel  of  the  saddle.  He  was 
not  thrown,  but  felt  himself  violently  jarred.  His  first 
impression  was  that  he  had  smashed  the  testes,  and  that 
blood  was  running  down  his  thighs.  He  placed  his 
hand  instinctively  to  the  part,  but  finding  no  bleeding 
concluded  that  an  internal  laceration  had  taken  place. 
He  gradually  fainted  away  on  his  horse  ;  was  taken  off 
and  carried  home  in  a  cart,  a  distance  of  about  four 
miles.  He  was  found  to  be  completely  paralyzed  as  to 
motion  in  his  lower  extremities,  and  there  was  not  the 
slightest  power  below  the  pelvis.  When  the  limbs  were 
moved  he  suffered  intense  agony  in  the  middle  of  the 
back.     There  was  a  disposition  on  the.i:)art  of  the  right 

93 


94  CdNCUSSION  FROM 

lower  extremity  to  become  abducted,  to  "  stray  away," 
and  he  suffered  great  pain  when  it  was  replaced  in  the 
straight  position.  He  had  control  over  the  bladder, 
but  not  over  the  sphincter  ani ;  there  was  no  priapism. 

He  was  placed  on  a  water-bed,  treated  by  dry  cup- 
ping to  the  spine,  and  had  small  doses  of  the  perchloride 
of  mercury  in  bark.  I  saw  him  on  April  9,  five  weeks 
after  the  accident,  in  consultation  with  Mr.  Francis.  I 
found  that  there  was  some  improvement  in  his  condi- 
tion ;  that  the  pains  in  the  limbs  were  less  severe,  and 
that  the  power  over  the  sphincter  ani  had  been  in  some 
measure  regained,  though  flatus  still  at  times  escaped 
involuntarily.  The  left  leg  and  foot  were  weaker  than 
the  right,  and  felt  very  cold  and  even  numb.  When 
out  of  bed  he  could  scarcely  move,  aud  only  with 
great  difficulty ;  his  legs  became  deeply  cynaosed  ;  he 
felt  faint  and  was  obliged  to  lie  down  again.  When 
recumbent  he  could  move  the  legs  somewhat.  His  gen- 
eral health  was  good  ;  head  free ;  spirits  and  courage 
excellent.  He  gradually  improved  up  to  May  4,  when 
he  got  a  severe  pleuritic  stitch  in  the  right  side,  for 
which  he  was  blistered  with  advantage.  On  May  21,  a 
severe  attack  of  obstructive  phlebitis  developed  itself 
on  the  right  leg,  the  saphenous  vein  becoming  blocked, 
and  the  common  femoral  implicated,  with  great  cedema 
of  the  limb.  This  was  appropriately  treated,  and  he 
made  good  recovery  from  it. 

June  2  he  dined  downstairs,  and  on  the  9th  was  able 
to  walk  to  his  stables,  and  rapidly  improved  in  his 
power  of  locomotion.  On  the  29th  he  was  seized  with 
a  severe  stitch  in  the  right  side.  This  gradually  in- 
creased until  July  7,  when  Mr.  Marriott,  of  Leicester, 
who  had  been  called  in,  found  effusion  up  to  a  height 
of  four  inches,  attended  by  the  most  excruciating  pain. 
The  following  day  the  left  pleura  became  implicated. 

On  July  9  I  saw  him  in  consultation  with  Mr.  Mar- 
riott, and  found  him  in  a  most  precarious  state.  Exten- 
sive pleuritic  effusion  on  both  sides  ;  double  pneumonia  ; 
dusky  countenance ;  deep  rusty-colored  sputa ;  pulse 
120;  temperature  101.2°;  respiration  44.  He  was 
ordered  five  grains  of  carbonate  of  ammonia,  and  chloric 


GENERAL  SHOCK.  95 

ether  every  four  hours  ;  two  drachms  of  brandy  every 
alternate  four  hours,  and  one  grain  of  calomel  with  one 
sixth  of  a  grain  of  morphia  at  night.  Under  this  treat- 
ment he  gradually  improved,  so  that  on  the  14th  Mr. 
Marriott  wrote  that  the  pleuritic  effusion  was  subsiding  ; 
lungs  clearing  up  ;  respiration  tranquil,  18  to  20;  pulse 
100  ;  temperature  99°  ;  sputa  scarcely  tinged  with  blood. 
From  this  time  his  improvement  was  progressive.  It 
ought  to  be  observed  that  previous  to  his  attacks  of 
phlebitis  and  pleurisy  he  had  been  very  sick  for  several 
days. 

In  September  he  went  to  Brighton  in  a  state  of  much 
debility.  He  could  only  walk  with  difficulty,  and  with 
the  aid  of  crutches  or  two  sticks.  Scarcely  able  to 
crawl,  he  stayed  there  a  month  ;  took  Turkish  baths 
with  much  advantage,  leaving  greatly  improved  in 
motor  power  and  general  health.  From  this  time  his 
recovery  was  progressive,  and  the  recovery  so  far  as  the 
paraplegia  and  spinal  symptoms  was  concerned  was 
complete,  the  patient  being  able  to  walk  and  ride  with- 
out any  sign  of  weakness.  After  m.uch  exercise  he  felt, 
however,  a  dull  aching  pain  in  the  lumbar  spine. 

This  case  is  an  excellent  illustration  of  the  superven- 
tion of  phlebitis  and  pleuro-pneumonia  inflammations 
after  injury  of  the  spine,  and  paraplegia,  probably 
dependent  on  meningeal  extravasation. 

There  was  the  clinical  sequence  : — i  .Severe  concussion 
of  spine  from  below  upwards.  2.  Immediate  paraplegia 
with  external  ecchymosis.  3.  Thrombosis  of  saphena 
and  femoral  veins.  4.  Acute  ( embolic )  pleuro-pneu- 
monia.    5.  Eventual  recovery. 

Case  23. — Fall  in  Hunting. — No  Direct  Bloiu  on 
Head  or  Back — Slow  Developinent  of  Symptoms. — H.  B. 
aged  30,  groom  in  a  hunting-stable,  was  sent  to  me 
March,  8,  1872.  Always  active  and  healthy.  Restated 
that  on  Dec.  26,  1871,  was  thrown  on  soft  grown  whilst 
going  fast ;  had  no  blow  on  head  or  back,  but  was  struck  . 
on  the  chest  by  the  horse  in  getting  up.  He  thought 
nothing  of  it,  and  went  on ;  felt  no  bad  effect  for  two 
or  three  days ;  then  had  *'  faltering  "  in  the  legs,  which 
felt  numb  and  cold  ;  he   could  not    walk   or  stand   for 


96  CONCUSSION  FROM 

any  length  of  time  without  support,  and  had  been 
obliged  to  use  a  stick  ever  since.  On  the  fifth  day 
(Dec.  31)  he  began  to  suffer  in  his  head.  Since  then 
till  the  time  I  saw  him  he  had  had  the  following  symp- 
toms :  viz.,  a  constant  "  whirl  "  in  his  head  ;  giddiness ; 
confusion  of  thought  and  forgetfulness  of  ordinary  oc- 
currences ;  slight  deafness  in  both  ears,  but  especially  in 
the  right ;  feeling  of  numbness  in  both  legs  ;  the  sphinc- 
ters acted  normally,  and  there  was  no  pain  in  the  head 
or  spine  ;  he  walked  with  a  tottering  unsteady  gait, 
and  with  the  aid  of  a  stick  ;  he  moved  the  feet  with 
difficulty,  and  there  was  slight  impairment  of  sensation 
as  well  as  of  motion  ;  sight  good  ;  pulse  ']2  ;  bowels 
regular.  He  had  been  well  leeched,  blistered,  and  pur- 
ged before  I  saw  him  ;  but  without  much,  if  any  benefit. 
I  put  him  on  the  course  of  the  perchloride  of  mercury 
and  quinine. 

March  22. — He  had  considerably  improved  in  all  the 
nervous  symptoms,  but  felt  very  weak.  I  ordered  the 
perchloride  of  iron  instead  of  that  of  mercury. 

April  30. — Felt  stronger  and  better,  but  his  head 
swam  if  he  hurried  himself ;  he  could  walk  better,  but 
was  not  quite  safe  without  the  stick ;  he  was  still  unable 
to  ride,  as  he  found  his  head  became  confused,  and  he 
complained  of  a  loud  noise  like  that  of  an  engine  in  it ; 
he  had  become  very  deaf,  so  that  it  was  necessary  to 
call  loudly  to  him.  This  interfered  much  with  his  com- 
fort and  safety.  Could  not  sleep  well  ;  pulse  79,  soft. 
Ordered  in  addition  to  the  iron,  the  bromide  of  potas- 
sium, which  he  took  with  much  benefit. 

Case  24. — Fall  in  Hunting — Slow  Development  of 
Symptoms  after  Slight  Blow  on  Head. — W.  A.,  aged  42, 
consulted  me  on  Feb.  6,  1872,  by  the  advice  of  Dr. 
Cowan,  of  Glasgow.  He  had  been  a  man  of  active 
habits,  addicted  to  field  sports.  Stated  that  twelve 
years  ago  he  had  a  heavy  fall  in  hunting,  the  conse- 
quences of  which  he  felt  in  the  way  of  giddiness,  con- 
fusion of  thought,  and  general  ill  health  for  about  a 
year.  At  the  expiration  of  that  time  he  recovered,  and 
was  able  to  resume  his  usual  occupations  at  the  desk 
and  in  the  field.     In   March,    1870,   nearly  two   years 


GENERAT.  SHOCK.  97 

before  I  saw  him,  he  had  another  fall,  striking  the  head 
on  the  left  side,  but  not  materally  brusing  or  otherwise 
injuring  it  externally.  He  was  not  stunned ;  he  rode 
the  whole  day,  went  to  a  dinner  party  afterwards,  next 
day  he  went  to  business,  and  to  a  ball  in  the  evening, 
feeling  no  ill  effects  of  his  accident.  On  the  fourth 
day  he  woke  giddy,  had  double  vision,  pain  across  the 
forehead,  confusion  of  thought,  inability  to  concentrate 
his  thoughts,  &c.,  and  was  obliged  to  give  up  all  occu- 
pation for  two  months.  He  then  returned  to  business 
but  found  that  he  could  not  concentrate  his  thoughts 
or  devote  himself  so  closely  to  it  as  before  the  accident. 
The  double  vision  also  continued  for  nearly  a  twelve- 
month, when  he  thought  he  had  fairly  recovered.  On 
resuming  his  former  life  he  felt  that  he  was  not  equal 
to  it.  He  now  began  to  suffer  from  extreme  nervous 
depression  ;  a  sense  of  exhaustion  after  slight  mental 
exertion  or  bodily  efforts.  His  appetite  failed  him  ; 
latterly  he  had  been  able  to  eat  little  solid  food.  Had 
become  emaciated,  and  lost  more  than  a  stone  in 
weight.  His  pulse  was  feeble,  and  about  90.  His 
sight  was  not  good,  but  the  pupils  were  remarkably 
contracted — looked  like  pin-hole  apertures  in  the  iris. 
He  passed  much  pale  urine  of  light  specific  gravity,  but 
otherwise  normal.  The  treatment  on  which  he  was 
put  consisted  of  cod-liver  oil,  nux  vomica,  &c.,  with 
carefully  regulated  diet  and  rest. 

This  case  is  an  instance  of  the  slow  development, 
after  an  interval  of  apparent  health,  of  a  long  continued 
train  of  cerebral  symptoms  from  a  slight  but  direct 
blow  on  the  head. 

Case  25. — Carriage  Accident — No  Direct  Injury  of 
Head  or  Spine — Slozv  Devolopment  of  Symptoms — Pa7sy 
and  A  noesthesia  in  one  Side — -HypercEstJiesia  in  other — 
Gradual  Recovery. — A  gentleman,  aged  44,  was  injured 
on  Jan.  16,  1874,  on  his  way  to  an  evening  party,  by 
the  brougham  in  which  he  was  driving  being  upset  by 
a  tram  car.  He  was  not  bruised,  stunned  or  visibly 
injured.  He  went  to  the  party  where,  though  feeling 
nervous  and  shaken,  he  danced  till  3  a.  m.  He  returned 
home,  and  though  not  feeling  well,    went   to   business, 

7 


98  CONCUSSION   FROM 

the  next  day  the  17th.  In  the  afternoon  of  that  day, 
about  eighteen  or  twenty  hours  after  the  accident,  he 
felt  uneasy  sensations  in  the  right  hand.  This  became 
gradually  palsied  and  anaesthesic.  On  the  19,  the  third 
day  after  the  accident,  he  was  seized  with  severe  pain 
in  the  lower  cervical  and  upper  dorsal  spines,  and  the 
left  upper  extremity  became  suddenly  hypersesthesic. 
It  was  especially  sensitive  to  the  cold,  and  the  applica- 
tion of  cold  water  or  the  impact  of  a  cold  current  of  air 
caused  him  to  feel,  as  he  said,  ''  scalded  by  ice." 

On  the  20th  he  lost  power  in  the  right  leg,  and  the 
palsy  gradually  crept  on,  involving  the  left  lower 
extremity ;  the  sphincters  were,  however,  not  affected. 
He  was  attended  by  Mr.  Llewellyn,  Dr.  Moxon,  and 
Mr.  Jabez  Hogg,  and  was  treated  with  large  doses  of 
iodide  of  potassium.  When  I  saw  him  on  Jan.  20, 
1875,  ^  year  after  the  accident,  he  had  in  a  great  meas- 
ure recovered.  The  right  arm,  hand,  leg,  and  foot  were, 
however,  still  partially  paralyzed,  with  some  contrac- 
tion about  the  muscles  of  the  shoulder  and  leg,  so  as  to 
impair  the  use  of  the  limbs.  He  could  not  write  as 
before,  could  not  walk  up  and  down  stairs  except  step 
by  step,  could  not  dress  or  undress  without  assistance. 
His  business  aptitude  was  greatly  reduced. 

This  case  is  remarkably  interesting  in  several  respects: 
I.  That  the  paralysis  and  spinal  symptoms  did  not 
begin  to  show  themselves  for  nearly  24  hours  after 
the  accident.  2.  That  there  had  been  no  blow  or  direct 
injury  to  the  spine.  3.  That  the  symptoms  were  clearly 
explicable  by  Brown  Sequard's  experiments  on  semi- 
section  of  the  cord  ;  and,  lastly,  the  contraction  of  some 
of  the  muscles  and  the  absence  of  palsy  of  the  sphinc- 
ters, indicated  that  the  lesion  was  probably  meningeal, 
in  great  part  at  least. 

Case  26. — Concussion  of  Spine  by  Fall  on  Feet — 
Gradual  Superve7ition  of  Paralysis — Death. — On  Nov. 
17,  1861,  I  saw,  in  consultation  with  Dr.  Strong,  of 
Croydon,  Mrs.  B.,  aged  32.  She  stated  that  in  Novem- 
ber, i860,  whilst  going  down  stairs,  she  accidentally 
stepped  upon  the  side  of  a  pail,  and  slipped  forwards, 
bumping  down  three  or  four  stairs  forcibly  on  her  heels. 


GENERAL   SHOCK.  99 

She  did  not  lose  her  footing,  did  not  fall,  and  did  not 
strike  any  part  of  the  body  or  head.  Of  this  she  was 
quite  certain.  She  felt  nervous,  faint,  and  shaken  at 
the  time,  and  was  obliged  to  take  some  brandy.  At 
the  period  of  the  occurrence  of  the  accident,  and  up  to 
that  time,  she  had  been  a  strong,  healthy,  and  active 
woman.  She  w^as  married,  and  the  mother  of  two 
children.  She  had  never  suffered  from  any  disease  of 
the  nervous  system,  or  from  any  serious  complaint. 

Two  days  after  the  trifling  accident  that  has  just 
been  described,  she  was  attacked  with  neuralgic  pains  in 
the  right  side  of  the  head — apparently  hemicrania. 
For  this  she  was  treated  in  the  usual  way,  and  did  not 
feel  it  necessary  to  lay  up.  About  a  fortnight  after  the 
accident,  she  felt  numbness  and  tingling  conjoined  in 
the  right  arm,  hand,  and  leg,  and  also  on  the  right  side 
of  the  head,  where  the  neuralgia  had  previously 
existed.  The  numbness  after  a  time  extended  to  the 
right  half  of  the  tongue. 

When  I  saw  her  three  months  after  the  accident  the 
numbness  and  tingling  existed  unchanged  in  these 
parts,  and  the  left  hand  and  arm  had  also  begun  to  be 
affected.  She  felt  a  numb  sensation  in  the  little  and 
ring  fingers,  and  slightly  in  the  middle  finger. 

Although  there  was  this  numb  sensation  in  the  hands, 
and  in  the  right  leg,  she  had  no  impairment  of  motion. 
She  could  pick  up  a  pin,  untie  a  knot,  and  otherwise 
use  the  right  hand,  which  was  the  one  most  affected,  in 
ordinary  small  occupations.  She  could  stand  and  walk 
fairly  well. 

I  saw  the  patient  again  on  April  13,  four  months  after 
the  accident.  Notwithstanding  the  treatment  that  had 
been  adopted  (iron  and  strychnine),  she  Avas  weaker, 
looked  anaemic,  and  was  rather  worse,  so  far  as  the 
paralytic  symptoms  were  concerned.  She  could  no 
longer  pick  up  so  small  an  object  as  a  pin,  but  could 
pick  up  a  piece  of  money — a  shilling  for  instance.  The 
right  hand  and  leg  were  still  the  worst,  but  the  left 
limbs  were  more  affected  than  previously.  In  the  left 
hand  the  numbness  had  now  affected  the  little,  ring, 
and  middle  fingers,  with  the  tip  of  the  forefinger. 


ICX>  CONCUSSION   FROM 

From  this  time  there  was  a  very  slow  increase  in  the 
symptoms,  notwithstanding  a  great  variety  of  treat- 
ment to  which  the  patient  had  been  subjected  by  the 
many  different  medical  men  whom  she  had  seen.  On 
examining  her,  on  April  lo,  1866,  about  five  and  a  half 
years  after  the  accident,  with  Mr.  Ayling,  her  present 
medical  attendant,  she  told  me  that  she  felt  that  she 
was  progressively,  though  very  slowly,  getting  worse. 
She  had  an  anxious,  anaemic  look.  She  tottered  in 
walking,  so  that  in  going  about  the  room  she  supported 
herself  by  the  chairs  and  tables.  She  could  not  in  any 
way  Avalk  a  quarter  of  a  mile.  She  could  stand  unsup- 
ported on  the  left  leg,  but  she  immediately  fell  over  if 
she  attempted  to  do  so  on  the  right.  The  right  hand 
and  foot  were  much  colder  than  the  left.  The  paralysis 
of  the  hands  continued  much  the  same,  but  a  marked 
change  had  taken  place  in  the  right  hand  in  conse- 
quence of  the  contraction  of  all  the  fingers,  but  more 
especially  of  the  little  and  ring  fingers.  They  had 
become  rigid,  and  the  flexor  tendons  stood  out  strongly. 
She  could,  consequently,  scarcely  use  this  hand.  On 
testing  the  irritability  of  the  muscles  in  the  opposite 
limbs  by  galvanism,  the  contraction  was  almost  nil  in 
those  of  the  right  arm  and  hand.  Much  stronger, 
though  not  normally  strong,  on  the  left  side. 

She  complained  of  confusion  of  thought  and  loss  of 
memory ;  the  senses  were  unimpaired.  Appetite  was 
bad,  and  digestion  imperfect.  Urine  was  acid.  She 
could  hold  her  water  well. 

March,  1868. — Since  the  last  report  her  symptoms 
had  slowly  and  gradually  become  aggravated.  She  was 
now  almost  helpless.  There  was  partial  paralysis  of 
sensation  and  of  motion  in  both  lower  extremities,  but 
much  more  marked  in  the  right  than  in  the  left ;  so 
that  she  could  not  at  all  support  herself  without  a  stick 
or  holding  on  to  furniture.  The  right  hand  and  arm 
were  almost  numb,  the  fingers  drawn  up  and  clenched. 
She  could  not  dress  herself.  She  was  much  depressed 
in  spirits,  and  enfeebled  in  mind. 

From  this  time  she  slowly  became  worse,  gradually 
becoming  more  and  more  extensively  paralyzed,  and  at 


GENERAL  SHOCK.  lOI 

length  died  in  August,  1871,  from  the  remote  effects  of 
this  accident. 

In  this  case  a  very  trifling  accident  occasioned  a  jar 
which  was  communicated  to  the  feet,  and  evidently 
transmitted  to  the  nervous  centres,  leading  to  impair- 
ment of  innervation,  and  eventually  to  progressive  and 
incurable  paralysis. 

Case  2J .—General  Shock — Symptom  of  Concussion  of 
Cord — Slozu  Recovery. — H.  M.  L.,  a  surgeon,  aged  43, 
naturally  a  stout  healthy  man,  of  active  professional 
habits,  consulted  me  on  February  22,  1865.  Restated 
that  on  October  9,  1864,  he  was  in  a  railway  collision, 
by  which  he  was  thrown  forwards,  but  without  any 
very  great  violence.  He  received  no  blow  on  the  back, 
head,  or  other  part  of  the  body.  He  was  much 
frightened  and  shaken,  but  did  not  lose  consciousness. 

Beyond  a  general  sensation  of  illness,  he  did  not  suffer 
much  for  the  first  three  or  four  weeks  after  the  accident, 
but  he  was  not  able  to  attend  to  his  business  ;  could  not 
collect  his  thoughts  sufficiently  for  the  purpose. 

About  a  month  after  the  accident  he  began  to  suffer 
from  pain  across  the  loins.  He  could  not  walk  without 
great  fatigue.  He  lost  strength  and  flesh,  and  his  pulse 
became  habitually  much  more  frequent  than  natural, 
being  about  98  to  100. 

When  I  saw  him  four  and  a  half  months  after  the 
accident,  he  continued  much  in  the  same  state  ;  was  quite 
unfit  for  business,  and  had  been  obliged  to  relinquish 
practice ;  not  owing  to  any  mental  incapacity,  but 
entirely  owing  to  his  bodily  infirmities.  His  mind  was 
quite  clear,  and  his  senses  perfect,  though  over-sensitive  ; 
loud  and  sudden  noises  and  bright  light  being  particu- 
larly distressing  to  him. 

He  complained  chiefly  of  the  spine.  He  suffered 
constant  pain  in  the  lower  part  of  it,  in  the  lower  dorsal, 
and  the  lumbar  regions.  He  compared  the  sensation 
there  experienced  to  that  of  a  wedge  or  plug  of  wood 
driven  into  the  spinal  canal.  It  was  a  mixed  sensation 
of  pain  and  distension.  The  spine  generally  was  tender, 
and  the  pain  in  it  was  greatly  increased  by  manipulation, 
pressure,  and  percussion.     It  had  lost  its  normal  flexi- 


10^  CONCUSSION  FROM 

bility,  moved  as  a  whole,  so  that  he  could  not  bend  for- 
wards or  stoop.  There  was  no  pain  in  the  cervical 
region,  or  on  moving  the  head. 

He  complained  of  painful  numbness  and  formications 
in  the  right,  and  occasionally  down  the  left  leg.  The  - 
legs  were  stiff  and  weak,  especially  the  right  one.  He 
could  not  stand  unsupported  on  this  for  a  moment.  He 
walked  in  a  slow  and  awkward  manner,  straddled,  and 
was  not  able  to  place  the  feet  together.  If  told  to  stand 
on  his  toes,  he  immediately  fell  forwards.  He  had  lost 
control  over  the  limbs,  and  did  not  know  exactly  where 
to  place  the  feet.  He  had  a  frequent  desire  to  pass 
water,  suffered  greatly  from  flatus,  and  had  completely 
lost  all  sexual  desire  and  power.  The  pulse  was  at  98  ; 
appetite  bad  ;  digestion  impaired. 

I  saw  this  patient  again,  at  Brighton,  towards  the  end 
of  April,  seven  months  after  the  accident,  in  consulta- 
tion with  Mr.  Curtis,  and  found  that  his  condition  had 
in  no  way  improved.  I  saw  him  again  in  1878  with  Mr. 
Bellamy.  He  had  tried  to  follow  his  profession,  but 
was  unable  to  do  so.  He  had  partial  paralysis  of  the 
musculo-spiral  nerve  of  the  right  arm  with  atrophy  of 
the  muscles  supplied  by  it.  He  had  partial  paraplegia. 
I  believe  this  mischief  to  have  been  of  a  chronic  inflam- 
matory nature  ;  the  tenderness  of  the  spine,  the  feeling 
of  distension,  the  pain  on  movement,  and  the  habitually 
high  pulse,  pointed  in  this  direction. 

Case  28. — General  Shock — Symptoms  of  Spinal  Con- 
cussion and  Meningitis- — Very  Slow  and  Imperfect  Recov- 
ery.— Mr.  C.  W.  E.,  aged  about  50,  naturally  a  stout, 
very  healthy  man,  weighing  nearly  seventeen  stone,  a 
widower,  of  very  active  habits,  mentally  and  bodily,  was 
in  a  railway  collision  on  February  3,  1865.  He  was 
violently  shaken  to  and  fro,  but  received  no  bruise  or 
any  sign  whatever  of  external  injury.  He  was  neces- 
sarily much  alarmed  at  the  time,  but  was  able  to  pro- 
ceed on  his  journey  to  London,  a  distance  of  seventy  or 
eighty  miles.  On  his  arrival  in  town  he  felt  shaken  and 
confused,  but  went  about  some  business,  and  did  not 
lay  up  until  a  day  or  two  afterwards.  He  was  then 
obliged  to  seek  medical  advice,  and  felt  himself  unable 


GENERAL  SHOCK.  I03 

to  attend  to  his  business.  He  slowly  got  worse,  and 
more  out  of  health.  He  was  obliged  to  have  change  of 
air  and  scene,  and  gradually  but  not  uninterruptedly, 
continued  to  get  worse,  until  I  saw  him  on  March  26, 
1866,  nearly  fourteen  months  after  the  accident.  Dur- 
ing this  long  period  he  had  been  under  the  care  of  vari- 
ous medical  men  in  different  parts  of  the  country,  and 
had  been  most  attentively  and  assidiously  treated,  by 
Dr.  Elkington,  of  Birmingham,  and  by  several  others, 
as  Dr.  Bell  Fletcher,  Dr.  Gilchrist,  Mr.  Gamgee,  Mr. 
Martin  &c.  He  had  been  anxious  to  resume  his  busi- 
ness, which  was  of  an  important  official  character,  and 
had  made  many  attempts  to  do  so,  but  invariably  found 
himself  quite  unfit  for  it,  and  was  most  reluctantly  com- 
pelled to  relinquish  it. 

When  I  saw  him  at  this  time  he  was  in  the  following 
state: 

He  had  lost  about  twenty  pounds  in  weight,  was 
weak,  unable  to  walk  a  quarter  of  a  mile,  or  to  attend 
to  any  business.  His  friends  and  family  stated  that  he 
was,  in  all  respects,  ''an  altered  man."  His  digestion 
was  impaired,  and  his  pulse  was  never  below  96. 

He  complained  of  loss  of  memory,  so  that  he  was 
often  obliged  to  break  off  in  the  midst  of  a  sentence, 
not  being  able  to  complete  it,  or  to  recollect  what  he 
had  commenced  saying.  His  thoughts  were  confused  and 
he  could  not  concentrate  his  attention  beyond  a  few  min- 
utes upon  any  one  subject.  If  he  attempted  to  read, 
he  was  obliged  to  lay  aside  the  paper  or  book  in  a  few 
minutes,  as  the  letters  became  blurred  and  confused. 
If  he  tried  to  write,  he  often  mis-spelt  the  commonest 
words;  but  he  had  no  difficulty  about  figures.  He  was 
troubled  with  horrible  dreams,  and  waked  up  frightened 
and  confused. 

His  head  was  habitually  hot,  and  often  flushed.  He 
complained  of  a  dull  confused  sensation  within  it,  and 
of  loud  noises  which  were  constant. 

The  hearing  of  the  right  ear  was  very  dull.  He  could 
not  hear  the  tick  of  an  ordinary  watch  at  a  distance  of 
six  inches  from  it.  The  hearing  of  the  left  ear  was 
normal;  he  could  hear  the  tick  at  a  distance  of  about 


104  CONCUSSION  FROM 

twenty  inches.  Noises,  especially  of  a  loud,  sud- 
den, or  clattering  character,  distressed  him  greatly.  He 
could  not  bear  the  noise  of  his  own  children  at  play. 

The  vision  of  the  left  eye  had  been  weak  from  child- 
hood. That  of  the  right,  which  had  always  been  good, 
had  become  seriously  impaired  since  the  accident.  He 
suffered  from  muscse  volitantes,  and  saw  a  fixed  line  or 
bar,  vertical  in  direction,  across  the  field  of  vision.  He 
complained  also  of  flashes,  stars,  and  colored  rings. 

Light,  even  of  ordinary  day,  was  especially  distress- 
ing to  him.  In  fact,  the  eye  was  so  irritable  that  he 
had  an  abhorrence  to  light.  He  habitually  sat  in  a 
darkened  room,  and  could  not  bear  to  look  at  artificial 
light — as  of  gas,  candles,  or  fire.  This  intolerence  of 
light  gave  a  peculiarly  frowning  expression  to  his  coun- 
tenance. He  knitted  and  depressed  his  brows  in  order 
to  shade  his  eyes. 

The  senses  of  smell  and  taste  seemed  to  be  somewhat 
perverted.  He  often  thought  that  he  smelled  fetid 
odors  which  were  not  appreciable  to  others,  and  he 
had  lost  his  sense  of  taste  to  a  great  degree.  He  com- 
plained of  a  degree  of  numbness,  and  of  "  pins  and 
needles  "  in  the  left  arm  and  leg,  also  of  pains  in  the 
left  leg,  and  a  feeling  of  tightness  or  constriction.  All 
these  symptoms  were  worst  on  first  rising  in  the 
morning. 

He  walked  with  great  difficulty,  and  seldom  without 
the  aid  of  a  stick;  whilst  going  about  a  room  he  sup- 
ported himself  by  taking  hold  of  the  articles  of  furniture 
that  came  in  his  way.  He  did  not  bring  his  feet 
together — straddled  in  his  gait — drew  the  left  leg  slowly 
behind  the  right — moved  it  stiffly  and  kept  the  foot 
flat  in  walking,  so  that  the  heel  caught  the  ground  and 
the  limb  appeared  to  drag.  He  had  much  difficulty  in 
going  up  and  down  stairs,  could  not  do  so  without 
support. 

He  could  stand  on  the  right  leg,  but  if  he  attempted 
to  do  so  on  the  left  it  immediately  bent  and  gave  way 
under  him,  so  that  he  fell. 

The  spine  was  tender  on  pressure  and  on  percussion 
at  these  points — viz.,  at  lower  cervical,  in  middle  dorsal. 


GENERAL  SHOCK.  I05 

and  in  lumbar  regions.  The  pain  in  these  situations  was 
increased  on  moving  the  body  in  any  direction,  but 
especially  in  the  antero-posterior.  There  was  a  degree 
of  unnatural  rigidity,  of  want  of  flexibility,  about  the 
spine,  so  that  he  could  not  bend  the  body — he  could 
not  stoop  without  falling  forwards. 

On  testing  the  irritability  of  the  muscles  by  gal- 
vanism, it  was  found  to  be  very  markedly  less  in  the  left 
than  in  the  right  leg. 

The  genito-urinary  organs  were  not  affected.  The 
urine  was  acid,  aud  the  bladder  neither  atonic  nor 
unduly  irritable. 

The  opinion  that  I  gave  In  this  case  was  to  the  effect 
that  the  patient  had  suffered  from  concussion  of  the 
spine — that  secondary  inflammatory  action  of  a  chronic 
character  had  been  set  up  in  the  meninges  of  the  cord 
— that  there  was  partial  paralysis  of  the  left  leg,  pro- 
bably dependent  on  structural  disease  of  the  cord  itself 
— and  that  the  presence  of  cerebral  symptoms  indicated 
the  existence  of  an  irritability  of  the  brain  and  its 
membranes. 

I  saw  the  patient  again  on  April  18,  1867,  two  and  a 
half  years  after  the  accident.  He  then  suffered  much 
from  pain  in  the  head,  and  in  the  cervical  spine.  He 
was  subject  to  fits  of  continual  depression,  was  generally 
nervous  and  little  fitted  for  his  ordinary  business, 
memory  was  defective,  and  ideas  unconnected.  The 
head  felt  hot,  face  had  a  somewhat  heavy  expressionless 
look,  pulse  96  to  98,  digestion  bad,  urine  phosphatic, 
left  leg  numb,  with  occasional  darts  of  pain  and  sensa- 
tion of  ''  pins  and  needles."  It  was  colder  than  right  leg. 
Case  29. — -General  Shock — Concussion  of  Spine — 
Chronic  Meningitis — Severe  Symptons — Slow  and  Incom- 
plete Recovery. — The  following  case  presents  some  very 
remarkable  and  unusual  nervous  phenomena,  resulting 
from  railway  shock,  which  I  will  briefly  relate  to  you. 
"■  March  i,  1865. — Mr.  D.  a  man  of  healthy  constitu- 
tion and  active  habits,  aged  33,  was  traveling  in  an 
"  express  "  (third  class,  with  divided  compartment),  and 
was  seated  with  his  back  to  the  engine.  When  near 
Doncaster,  the  train  going  at  about  thirty  miles  an  hour, 


IC6  CONCUSSION  FROM 

ran  into  an  engine  standing  on  the  line.  He  was  thrown 
violently  against  the  opposite  side  of  the  carriage,  and 
then  fell  on  the  floor. 

**  Immediate  Effects. — There  was  a  swelling  the  size 
of  an  egg  over  the  sacrum,  severe  pain  in  the  lower  part 
of  the  spine,  which,  on  arriving  at  Edinburgh  the  same 
day,  had  extended  up  the  whole  back  and  into  the  head, 
producing  giddiness  and  dimness  of  sight.  These,  with 
tingling  feelings  in  the  limbs  (particularly  the  left),  great 
pain  in  the  back,  and  tenderness,  to  the  touch,  sickness 
in  the  mornings,  and  lameness,  continued  for  the  first 
fortnight. 

'*  The  treatment  adopted  consisted  of  blisters  and  hot 
fomentations  to  the  spine. 

**  The  patient  seemed  to  improve,  and  the  pain 
between  the  shoulders  to  lessen  after  these  applications. 

**  28th, — He  was  seen  by  an  eminent  surgeon,  who 
ordered  him  to  go  about  as  much  as  possible,  but  to 
avoid  cold.  The  result  of  this  advice  was  that  he  found 
the  whole  of  the  symptoms  much  increased,  with  pro- 
stration and  lameness. 

"  April  20th. — Left  for  London,  breaking  journey  for 
a  week  in  Lancashire,  greatly  fatigued  by  journey.  A 
discharge  came  on  from  the  urethra,  the  lameness  was 
much  increased,  he  could  not  advance  the  left  leg  in 
front  of  the  right,  and  there  was  great  prostration." 

I  saw  him,  in  consultation  with  Mr.  Hewer,  May  i, 
1865,  when  I  received  the  above  account  from  the 
patient.  He  was  then  suffering  from  many  of  the  "■  sub- 
jective *'  phenomena  which  are  common  to  persons  who 
have  incurred  a  serious  shock  to  the  system.  But  in 
addition  to  these,  he  presented  the  following  somewhat 
peculiar  and  exceptional  symptoms  : — 

I.  An  extreme  difficulty  in  articulation,  of  the  nature 
of  a  stammer  or  stutter  of  the  most  intense  kind,  so 
that  it  was  extremely  difficult  to  hold  a-continuous  con- 
versation with  him.  Although  he  had  previously  to 
the  accident  some  impediment  in  his  speech,  this  had 
been  aggravated  to  the  degree  just  mentioned,  so  as  to 
constitute  the  most  marked  stutter  that  I  have  ever 
heard  in  an  adult. 


GENERAL   SHOCK.  I07 

2.  A  very  peculiar  condition  of  the  spine  and  the 
muscles  of  the  back. 

The  spine  was  rigid — had  lost  its  natural  flexibility 
to  antero-posterior  as  well  as  to  lateral  movement. 

There  was  an  extreme  degree  of  sensibility  of  the 
skin  of  the  back,  from  the  nape  of  the  neck  down  to 
the  loins.  This  sensibility  extended  for  about  four 
inches  on  either  side  of  the  spine.  It  was  most  intense 
between  the  shoulders. 

This  sensibility  was  both  superficial  and  deep.  The 
superficial  or  cutaneous  sensibility  was  so  marked,  that 
on  touching  the  skin  lightly  or  on  drawing  the  finger 
down  it,  the  patient  started  forwards  as  if  he  had  been 
touched  with  a  red-hot  iron.  There  was  also  deep  pain 
on -pressure  along  the  whole  length  of  the  spine,  and  on 
twisting  or  bending  it  in  any  direction. 

Whenever  the  back  was  touched  at  these  sensitive 
parts,  the  muscles  were  thrown  into  violent  contraction 
so  as  to  become  rigid,  and  to  be  raised  in  strong  relief, 
their  outlines  becoming  clearly  defined. 

3.  *The  patient's  gait  was  most  peculiar.  He  did  not 
carry  one  leg  before  the  other  alternately  in  the  ordi- 
nary manner  of  walking,  but  shuf^ed  sideways,  carrying 
the  right  leg  in  advance,  and  bringing  up  the  left  one 
after  it  by  a  series  of  short  steps.  He  could  alternate 
the  action  of  the  legs,  but  he  could  not  bring  one  leg  in 
front  of  the  other  without  twisting  the  whole  body  and 
turning,  as  on  a  pivot,  on  the  leg  that  supported  him. 
He  could  not  bend  the  thigh  on  the  abdomen. 

I  saw  this  patient  several  times  during  the  summer 
and  autumn.  In  the  early  part  of  December,  his  con- 
dition was  as  nearly  as  possible  the  same  as  that  which 
has  been  described  in  May,  no  change  whatever  in  pain 
or  gait  having  taken  place.  There  was  not  at  this  time, 
nor  had  there  ever  been, any  signs  of  paralysis,  but  he  com- 
plained of  the  sensation  of  a  tight  cord  round  the  waist. 

In  addition  to  Mr.  Hewer  and  myself,  this  patient 
was  seen  at  different  times  by  Sir  W.  Fergusson,  Drs. 
Reynolds  and  Walshe.  We  all  agreed  that  the  patient 
was  suffering  from  *'  concussion  of  the  spine,"  and  that 
his  ultimate  recovery  was  uncertain. 


I08  CONCUSSION   FROM 

After  the  trial  he  was  continuously  under  my  care, 
and  I  saw  him  at  intervals  of  about  a  month.  He  was 
treated  by  perfect  rest,  lying  on  a  prone  couch  ;  by  warm 
salt-water  douches  to  the  spine,  for  which  purpose  he 
resided  at  Brighton,  and  by  full  doses  of  the  bromide  of 
potassium.  Under  this  treatment  he  considerably 
improved  (May,  1866).  The  extreme  sensibility  of  the 
back  was  materially  lessened,  and  he  could  walk  much 
better  than  he  did.  He  also  stammered  less  vehemently 
but  he  still  had  considerable  rigidity  about  the  spine, 
could  ouly  walk  with  the  aid  of  a  stick,  and  retained 
that  peculiar  careworn,  anxious,  and  aged  look  that  is 
so  very  characteristic  of  those  who  have  suffered  from 
these  injuries. 

March  5,  1870,  five  years  after  the  accident,  this 
patient  called  on  me.  He  looked  pale,  haggard,  more 
than  his  real  age.  Had  done  no  business  since  the  trial. 
Still  felt  nervous,  when  put  to  anything  however  trivial. 
Still  felt  a  want  of  power  in  leg  and  hand,  as  if  asleep 
or  dead.  Still  had  tenderness  in  lower  dorsal  and  lumbar 
regions.  His  health  was  very  variable,  often  he  was 
unfit  for  any  any  work. 

Case  'ip.— Railway  Concussion — Slozv  Development  of 
Symptoms — Partial  Paralysis — Incomplete  Recovery. — 
E.  C,  aged  47,  a  gentleman  farmer,  hale,  hearty,  ath- 
letic, and  of  active  habits,  received  an  injury  in  a  rail- 
way collision  on  July  i,  1865  ;  the  carriage  in  which  he 
was  being  upset,  and  he  and  his  fellow  passengers  thrown 
violently  about.  At  the  time  he  did  not  feel  himself 
hurt,  was  able  to  creep  out  of  the  window  and  assist 
the  other  passengers,  and  then  went  on  to  Lowestoft, 
his  destination.  At  night,  however,  he  could  not  sleep, 
and  this  was  the  first  symptom  that  attracted  his  atten- 
tion. The  next  morning  he  felt  stiff,  and  complained 
of  creeping  sensations  up  and  down  the  back,  and  of 
unpleasant  sensations,  almost  amounting  to  pain,  in  the 
head.  By  the  middle  of  the  day  he  was  forced  to 
recline  on  a  couch  as  he  could  scarcely  sit  up.  He 
felt  very  unwell  for  several  days.  During  this  period 
he  had  sensations  as  if  electric  shocks  were  passing 
through  the  body  and  limbs.     He  returned  home,  con- 


GENERAL  SHOCK.  IO9 

tinued  to  feel  unpleasant  sensations  in  his  head,  back, 
&c.,  being  often  giddy,  but  was  still  able  to  take  a 
certain  amount  of  exercise,  and  even  to  ride  on  horse- 
back. He  continued  in  this  unsatisfactory  state  until 
August  12,  when  he  became  suddenly  extremely  giddy 
and  scarcely  able  to  stand.  His  head  became  very 
confused,  he  could  not  attend  to  the  business  on  which 
he  was  engaged,  and  seemed  to  have  lost  all  energy 
and  power.  He  continued  to  feel  the  electric  shocks 
through  the  body.  In  November  he  began  to 
suffer  from  an  increasing  difficulty  about  the  lower 
extremities.  He  was  obliged  to  leave  off  riding,  as  he 
had  entirely  lost  both  his  grip  and  the  power  of  balanc- 
ing himself.  He  also  found  that  he  walked  with  diffi- 
culty, and  occasionally  seemed  to  lose  control  over  his 
legs.  On  November  29,  when  getting  up  in  the  morn- 
ing, he  suddenly  fell,  and  probably  momentarily  lost 
consciousness.  He  lost  all  power  in  his  legs  and  suf- 
fered intense  pain  in  the  head.  As  he  was  gradually 
getting  worse,  he  came  up  to  London,  when  I  saw  him 
on  January  6,  in  consultation  with  Mr.  Calthrop,  At 
this  time  he  was  complaining  of  various  symptoms 
referable  to  the  head,  such  as  loss  of  memory,  inability 
to  attend  to  busines,  difficulty  in  grasping  a  subject. 
There  was  general  debility,  incapacity  for  exertion  ;  he 
was  unable  to  ride,  could  scarcely  walk,  looked  haggard 
and  ill,  and  felt  himself  a  perfect  wreck.  On  examining 
the  body  I  found  the  following  objective  signs.  There 
was  flabbiness  and  wasting  of  the  muscles  of  both  the 
lower  extremities  and  of  the  buttocks,  the  skin  hanging 
loose.  The  left  lower  extremity  was  more  shrunken 
than  the  right.  The  thigh  at  its  middle  was  one  inch 
smaller  in  circumference  ;  the  leg  at  the  calf  was  three- 
fourths  of  an  inch  smaller  than  the  right.  There  was  a 
considerable  diminution  in  the  temperature  of  the  limbs, 
especially  of  the  left,  which  was  very  considerably 
colder  than  the  right  and  the  rest  of  the  body.  The 
electric  irritability  of  the  muscles  was  very  materially 
diminished  in  both  lower  extremities  ;  it  was  nearly  lost 
in  the  left  leg  below  the  knee.  In  the  upper  extremi- 
ties it  was  extremely  active,  the  difference  being  very 


no  CONCUSSION  FROM 

striking.  The  pulse  was  quick,  varying  from  lOO  to 
no,  and  weak,  the  beats  intermittent  twice  in  the 
minute.  Ou  January  26  there  was  no  improvement; 
in  fact  he  was  in  more  suffering,  and  had  lost  all  power 
in  the  left  leg.  There  was  also  a  good  deal  of  pain  in 
the  spine  in  the  upper  dorsal  and  lumbar  regions,  more 
especially  on  the  left  side.  It  gave  him  pain  both  to 
lie  and  to  sit  on  the  left  side.  He  could  not  rise  from 
a  recumbent  position  without  assistance  from  one  or  two 
persons,  and  could  not  dress  without  help.  During  this 
period  he  suffered  much  from  pains  in  the  head  and  sing- 
ing in  the  left  ear.  On  April  27  I  again  saw  him  in  con- 
sultation with  Mr.  Calthrop  and  Mr.  Buller,  when  these 
symptoms  were  noted  as  continuing  without  any  change. 
This  state  of  things  continued  throughout  the  summer 
— the  legs  being  cold  and  almost  powerless,  the  pain  in 
the  head,  the  electric  shocks,  and  inability  to  move 
remaining  unaltered.  On  July  6  the  symptoms  con- 
tinued without  material  change.  He  went  to  Yarmouth 
for  change  of  air,  but  suffered  intensely  from  the  head, 
and  derived  no  benefit.  He  continued  under  my  obser- 
vation for  more  than  a  twelvemonth,  and  after  the  ter- 
mination of  the  legal  proceedings,  on  February  18,  1867, 
he  went  into  the  country.  No  material  improvement 
took  place  in  his  condition  for  a  very  considerable  length 
of  time,  and  up  to  the  present  time  there  has  been  no 
recovery  from  the  more  serious  symptoms. 

Case  31. — Railway  Concussion — Injury  to  Cervical 
Spine — Meningitis — Permanent  Injury — Paralysis  and 
Irritation  of  Spinal  Accessory ^  Micscnlo-Spiral,  and  Cir- 
cumjlex  Nerves. — J.  M.  was  injured  in  a  railway  accident 
on  October  29,  1866.  He  suffered irom  the  usual  symp- 
toms of  spinal  concussion,  for  which  he  was  treated  by 
Dr.  Woodford,  of  Bow,  with  whom  I  saw  the  patient 
in  consultation  on  November  30,  1867.  At  that  time 
he  presented  three  sets  of  symptoms  of  a  very  marked 
character,  referable  to  the  head,  to  the  spine,  and  to 
the  right  arm.  The  head  symptoms  consisted  of  an 
inability  to  concentrate  his  thoughts,  and  of  loss  of 
memory  on  many  points.  In  the  course  of  conversation 
he  ''dropped,"  to  use  his  own  word,  the  thread  of  the  dis- 


GENERAL   SHOCK.  Ill 

cussion.  There  was  a  complete  inaptitude  for  business. 
The  spine  was  evidently  the  seat  of  very  considerable 
mischief.  It  was  rigid,  moved  as  a  whole  when  he  was 
told  to  stoop,  and  was  extremely  painful  on  pressure 
and  on  movement  in  any  direction,  namely,  in  the  lower 
cervical  and  in  the  middle  and  lower  dorsal  regions. 
The  pain  in  this  situation  was  described  by  the  patient 
as  being  of  a  hot,  burning  character.  From  the  seat 
of  pain  in  the  neck  he  suffered  constant  spasmodic  pain 
shooting  down  the  right  arm  and  right  side  of  the  chest, 
with  frequent  cramps  in  the  muscles  of  the  arm.  From 
the  seat  of  pain  in  the  dorsal  region  he  complained  of 
the  sensation  as  of  a  cord  being  tightly  bound  round  his 
body  and  pressing  on  his  ribs.  The  right  arm  and 
hand  had  suffered  considerably.  There  was  great  loss 
of  muscular  power  in  the  limb,  so  that  the  patient  was 
unable  to  hold  it  up  in  a  horizontal  position,  or  to  sup- 
port it  extended  for  more  than  a  few  seconds.  The 
grasp  of  this  hand  was  much  weakened,  and  consider- 
ably feebler  than  that  of  the  left.  The  limb  was  wasted, 
more  particularly  below  the  elbow,  where  it  was  smaller 
than  the  left  arm.  The  hand  also  was  wasted,  more 
especially  about  the  muscles  of  the  thumb.  The  patient 
complained  of  severe  twitchings  and  spasmodic  pains 
shooting  down  the  fore-nnger  and  the  thumb.  The 
attitude  of  the  patient  was  very  remarkable  ;  he  stooped 
forwards,  and  the  right  shoulder  was  raised  about  two 
inches  higher  than  the  left.  This  position  was  never 
changed.  He  suffered  from  severe  spasmodic  pains 
through  the  side  of  the  neck  and  shoulder,  and  on 
examining  the  parts,  the  trapezius  and  sterno-mastoid 
muscles  were  found  extremely  tense.  The  muscles  that 
were  chiefly  wasted  in  the  right  arm  were  those  which 
are  supplied  by  the  musculo-spiral  nerve.  These 
muscles  had  lost  their  electric  irritability.  The  raising 
of  the  right  shoulder  was  evidently  due  to  irritation  of 
the  spinal  accessory  nerve,  in  consequence  of  which  the 
trapezius  was  kept  contracted,  and  the  spasms  that 
passed  through  it  were  due  to  this  irritation.  The  con- 
clusions arrived  at  in  connection  with  this  case  were 
that  at  the   time  of  the  accident  there  had   been  some 


112  CONCUSSION  FROM 

concussion  of  the  brain  and  of  the  spinal  cord  ;  that 
the  brain  was  still  suffering  from  the  consequences  of 
that  concussion,  but  only  to  a  slight  degree  ;  that  the 
spinal  cord  had  been  severely  injured  ;  that  there  was 
evidence  of  chronic  inflammation  and   irritation  of  it, 
these  changes  being  seated  in  the  meninges  of  the  cord  ; 
that  partial  paralysis  of  the  musculo-spiral  nerve  had 
already  taken  place  ;  that  the  wasting  of  the  limb  and 
arm  was  dependent  on  the  paralysis  of  this  nerve ;  that 
in  addition  to  the  paralysis,  the  nerves  of  the  brachial 
plexus  were  probably  much  irritated,  as  shown  by  the 
painful  cramps  that  manifested  themselves  in  the  arm. 
The  condition  of  the  shoulder  was  due  to  spasm  of  the 
muscles  supplied  by  the  spinal  accessory  nerve.     I  saw 
the  patient  on  February   12,  1868.     In  many  respects 
he  was  then  worse  than  I  had  seen  him  in  the  previous 
December.     He  looked  very  ill ;  he  suffered  more  than 
previously  from  twitchings  in  the  neck  and  right  arm. 
I  found  the  paralysis  of  the  right  arm  was  more  com- 
plete than  it  had  been.     He  could  not  move  the  arm 
from  the  side,  and  the  paralysis  extended  to  the  mus- 
cles about   the   shoulder,  to  those,   in   fact,  that  were 
supplied    by   the   circumflex    nerve.       There   was   an 
utter  absence  of  all   electric   irritability  of  the  muscles 
supplied   by  the   musculo-spiral  and   circumflex  nerves. 
I  saw  him  again  on  January  18,  1869,  with   Dr.  Wood- 
ford.    We  found  that  he  still  suffered  from  irritation 
of  the  brain  and  spinal  cord,  the  spine  continuing  to 
be  rigid  and  painful  ;  that  the  right  shoulder  was  drawn 
up  and  displaced  forwards  ;  that  the  right  arm  and  hand 
were   paralyzed   so  as  to  be  absolutely  useless  for  all 
practical  purposes,  and  that  the  right  leg  had  gradually 
become  to  a  great  extent   powerless.     By  order  of  the 
Court  of  Queen's  Bench,  he  was  seen  on  May  28,  1869, 
by  Mr.,  now  Sir  James,   Paget,  who  found  that   J._M. 
complained   of   constant   pain   in  his   back,   extending 
across  the  shoulder  and  to  the  back  of  his  head  ;  of 
pains  passing  through  his  chest,  and  of  pain  round  the 
chest  as  if  he  were  being  compressed  ;  of  aching  down 
the  right  thigh  as  far  as  the  heel.     The   right  shoulder 
was    always   slightly    raised,    and    he  had    occasionally 


GENERAL   SHOCK.  113 

involuntary  twitchings  of  its  muscles.  The  muscular 
power  of  the  right  shoulder  and  forearm  was  much 
decreased,  and  he  was  subject  to  frequent  twitchings  of 
the  right  lower  lim.bs,  which  prevented  his  walking 
more  than  very  short  distances,  or  taking  any  active 
exercise.  The  manner  of  walking  was  slow  and  feeble. 
During  the  last  two  years  he  had  wasted  very  much, 
and  his  skin  and  muscles  felt  soft  and  weak.  The  pulse 
varied  from  40  to  50.  His  bowels  and  lower  limbs  felt 
unnaturally  cold.  He  said  that  his  appetite  and  diges- 
tion were  always  bad,  that  he  never  slept  well,  and  that 
his    memory   was   impaired.     On    reference    to    these 

symptoms  of   injury  which    Mr.   M had    suffered 

since  October  1866,  it  was  the  opinion  of  Sir  James 
Paget,  in  which  Dr.  Woodford  and  I  fully  concurred, 
that  there  was  no  reason  to  think  that  his  sufferings  on 
the  whole  were  materially  decreasing,  and  there  was  no 
doubt  that  they  were  the  consequence  of  severe  injury 
to  the  spinal  cord.  We  were  further  of  opinion  that  he 
would  never  recover  health  as  he  had  had  it  before  the 
injury,  or  be  again  fit  for  the  active  business  in  which 
he  had  been  engaged.  On  February  15,  1871,  four 
and  a  half  years  after  the  accident,  J.  M.  wrote  to  say 
that  he  still  suffered  greatly.  His  arm  was  partially 
paralyzed  ;  the  thumb  useless ;  his  spine  tender,  and 
ached  on  movement  or  after  exertion  of  any  kind  ;  his 
nights  sleepless,  and  he  was  quite  unfit  for  the  ordinary 
business  of  life. 

There  are  several  points  worthy  of  observation  in 
railway  accidents.  Thus  it  often  happens  that  all  the 
persons  injured  in  any  given  collision  present  very  much 
the  same  class  of  symptoms.  In  some  cases  all  will  be 
but  slightly  shaken,  and  in  others  they  are  all  severely 
concussed.  This  may  be  accounted  for,  to  some  extent  at 
least,  and  in  some  cases,  though  certainly  not  in  all,  by 
the  severity  of  the  collision  and  the  resulting  intensity 
of  the  shock,  varying  in  different  accidents  according  to 
the  rapidity  with  which  the  train  is  travelling  at  the 
moment  of  the  collision,  or  the  force  with  which  it  is 
run  into  from  behind.  But  particular  and  special 
symptoms,  not  dependent  on  the  mere  severity  of  the 
8 


114  CONCUSSION   FROM 

shock;  are  sometimes  observable  in  all  who  suffer  in 
any  one  particular  accident.  Thus  in  some  cases  I 
have  seen  the  head,  in  others  the  spine,  in  others  again 
the  general  nervous  system  appear  in  all  the  sufferers  to 
have  sustained  the  greatest  amount  of  injury.  I  have 
seen  after  some  accidents  that  almost  all  the  injured 
persons  vomited ;  in  other  cases  this  symptom  has  been 
entirely  absent.  In  some  accidents  they  suffer  most 
from  concussion  of  the  brain,  or  general  nervous  shock ; 
in  others  from  concussion  of  the  spine.  Those  who  are 
asleep  at  the  time  of  the  accident  very  commonly  escape 
concussion  of  the  nervous  system.  They  may,  of  course, 
suffer  from  direct  and  possibly  from  fatal  injury  to  the 
head  or  trunk  ;  but  the  shock  or  jar,  that  peculiar 
vibratory  thrill  of  the  nervous  system  arising  from  the 
concussion  of  the  accident,  is  frequently  not  observed  in 
them,  whilst  their  more  wakeful  and  less  fortunate 
fellow-travelers  may  have  suffered  severely  in  this 
respect. 

I  have  often  remarked  that  in  railway  accidents  those 
passengers  suffer  most  seriously  from  concussion  of  the 
nervous  system  who  sit  with  their  backs  turned  towards 
the  end  of  the  train  which  is  struck.  Thus  when  a  train 
runs  into  an  obstruction  on  the  line,  those  who  are  sit- 
ting with  their  backs  to  the  engine  will  probably  suffer 
most ;  whilst  if  a  train  is  run  into  from  behind,  those 
who  are  facing  the  engine  will  most  frequently  be  the 
greatest  sufferers.  The  explanation  of  this  fact  appears 
to  me  to  be  as  follows :  When  a  train  runs  into  a  sta- 
tionary impediment,  its  momentum  is  suddenly  arrested, 
whilst  that  of  the  passengers  still  continues.  Those 
who  are  facing  the  engine  are  in  the  first  instance 
thrown  suddenly  and  violently  forwards  off  their  seats 
against  the  opposite  side  of  the  compartment ;  hence 
they  will  frequently  be  found  to  be  cut  about  the  head 
and  face,  and  more  especially  across  the  knees  and  legs, 
by  coming  in  contact  with  the  edge  of  the  opposite 
seats.  They  then  rebound,  and  in  the  rebound  may 
sustain  that  concussion  of  the  spine  which  they  escaped 
in  the  first  shock.  Those,  on  the  other  hand,  who  are 
sitting  with  their  backs  to  the  engine,  being  carried 


GENERAL   SHOCK.  II5 

backwards  when  the  momentum  of  the  carnage  is  sud- 
denly arrested  are  struck  at  once ;  and  if  traveling 
rapidly,  are  jerked  violently  against  the  backs  of  their 
seats,  and  thus  suffer  in  the  first  instance  and  b)'  the 
first  shock  from  concussion  of  the  spine.  The  force 
with  which  they  strike  the  partition  between  the  com- 
partments with  their  shoulders  or  loins  is  greatly  aug- 
mented by  their  opposite  fellow-travellers  being  thrown 
upon  them.  In  the  oscillation  and  to-and-fro  move- 
ment to  which  the  carriage  is  subjected  they  are  apt  to 
be  thrown  forwards,  and,  rebounding,  to  be  struck  again 
about  the  posterior  part  of  the  body.  They  are  more 
helpless  than  those  who  are  facing  the  engine,  who  fre- 
quently have  time  to  stretch  out  their  hands  in  order 
to  save  themselves,  or  to  clutch  hold  of  the  sides  of  the 
carriage  when  in  the  act  of  being  thrown  forwards. 
When  a  carriage  is  run  into  from  behind,  the  reverse  of 
this  takes  place,  and  the  carriage  is  driven,  as  it  were, 
against  those  passengers  who  have  got  their  backs 
turned  towards  the  hind  part  of  the  train.  In  the 
violent  oscillations  that  take  place  a  passenger  is  thrown 
backwards  and  forwards  by  a  kind  of  shuttlecock  action, 
aud  frequently  coming  in  contact  with  others  on  the 
opposite  side,  may  become  seriously  injured,  especially 
by  contusions  about  the  head.  The  oscillations  to 
which  the  body  is  subjected  in  these  accidents  are 
chiefly  felt  in  those  parts  of  the  vertebral  column  that 
admit  of  most  movement,  viz.,  at  the  junction  of  the 
head  and  neck,  of  the  neck  and  shoulders,  and  of  the 
trunk  and  pelvis.  Hence  it  is  that  the  spine  so  fre- 
quently becomes  strained  and  injured  in  these  regions 
by  railway  injuries. 


LECTURE  VI. 

ON   SPRAINS,  TWISTS,  AND   W^RENCHES   OF  THE   SPINE. 

Sprains,  strains,  wrenches  and  twists,  of  the  spine  are 
of  very  frequent  occurrence.  They  may  be  followed 
by  every  possible  kind  of   mischief  to  the  vertebral 


Il6  SPRAINS,   ETC., 

column,  its  bones  or  ligaments,  the  cord  or  its  mem- 
brane. 

The  symptoms  indicative  of  lesion  of  the  cord  or  its 
membrane  may  be  immediate,  or  they  may,  as  in  many 
of  the  cases  I  have  already  related,  come  on  slowly  and 
progressively. 

I  will  give  you  abundant  illustration  of  both  of  these 
methods  of  development  of  symptoms. 

It  is  important  to  bear  in  mind  that  the  vertebral 
column  is  more  apt  to  suffer  in  these  strains  of  the  spine 
than  in  the  other  forms  of  injury  that  we  are  discussing, 
and  that  in  serious  cases,  as  in  the  following,  the  full 
force  of  the  mischief  appears  to  be  expended  on  the 
spine  itself  independently  of  its  contents,  which  escape 
uninjured. 

Case  32. — Crush  of  the  Spinal  Column  from  Forcible 
Doubling  Forward — No  Permanent  Injury  to  the  Cord  or 
its  Membrane. — E.  B.,  26  years  of  age,  was  admitted 
under  my  care  at  the  University  College  Hospital  on 
February  8th,  1875.  He  stated  that  thirteen  weeks 
ago,  whilst  working  under  a  turn-table  at  a  railway  sta- 
tion, the  table  was  accidentally  turned  upon  him  so  that 
he  was  doubled  forward  underneath  it.  He  suffered 
intense  pain  in  the  back,  and  was  taken  to  a  hospital, 
where  he  remained  for  few  weeks  and  was  then  dis- 
charged. When  I  saw  him  he  presented  the  following 
symptoms :  He  could  not  stand  upright,  but  bent  for- 
wards. He  walked  with  difficulty  and  was  unable  to 
do  so  for  more  than  half  an  hour  at  a  time,  on  account 
of  the  pain  that  he  suffered  in  the  back,  round  the 
sides,  and  underneath  the  ribs.  On  examining  his  spine 
it  was  found  that  the  spinous  processes  of  the  loth  and 
1 2th  dorsal  vertebrae  projected,  whilst  between  them 
there  was  a  distinct  depression.  The  spinous  process 
of  the  nth  dorsal  vertebrae  was  broken  off  and  twisted 
out  of  the  perpendicular  so  as  to  lie  directly  across 
towards  the  left  side.  On  the  right  of  this  depression 
the  muscular  and  tendinous  structures  could  be  felt 
under  the  skin  loose.  When  lying  on  his  back  in  bed 
the  patient  was  unable  to  get  up  without  using  his 
hands  to  support  himself.     Both  the  lower  extremities 


OF  THE   SPINE.  11^ 

Were  wasted,  but  equally  so.  The  sensibility  of  both 
legs  was  equal  and  appeared  to  be  normal.  The  reflex 
irritability  was  also  equal  and  normal.  There  had  been 
no  tinglings  or  other  uneasy  sensations  in  the  limbs. 
On  applying  the  secondary  interrupted  current,  the 
muscular  irritability  appeared  to  be  the  same  in  the 
different  groups  of  muscles,  the  extensors,  the  peroneals 
and  the  flexors  in  both  legs.  If  there  was  any  differ- 
ence, which  was  doubtful,  it  appeared  to  be  rather  less 
in  the  extensors  of  the  right  leg,  and  the  patient 
appeared  not  to  be  able  to  support  himself  quite  so 
easily  on  the  toes  of  the  right  foot  as  he  could  on  those 
of  the  left.  There  was  no  paralysis  of  the  sphincters, 
and  no  sensation  as  of  a  cord  being  tied  round  the  body. 
This  case  illustrates  in  a  remarkable  manner  the  possi- 
bility of  the  existence  of  a  fractured  spine  attended  by 
displacement  of  bone,  without  any  sign  not  only  of 
paralysis,  but  even  of  meningeal  irritation,  and  shows 
that  the  electric  sensibility  and  irritability  of  the  lower 
limbs  may  continue  perfect  after  such  a  severe  injury. 

Boyer  relates  a  fatal  case  of  wrench  of  the  spine 
received  in  practising  gymnastics,  and  Sir  Astley  Cooper 
gives  an  instance,  to  which  I  shall  refer,  of  a  fatal  wrench 
of  the  spine  from  a  rope  catching  a  boy  round  the  neck 
whilst  swinging. 

In  two  cases  which  I  shall  relate,  the  injury  also 
arose  from  violence  applied  to  the  cervical  spine  ;  in  one 
from  a  railway  accident,  in  the  other  from  a  fall  from  a 
horse. 

These  wrenches  of  the  spine  are,  from  obvious  rea- 
sons, most  liable  to  occur  in  the  more  mobile  parts  of 
the  vertebral  column,  as  the  neck  and  loins  ;  less  fre- 
quently in  the  dorsal  region. 

In  railway  collisions,  when  a  person  is  violently  and 
suddenly  jolted  from  one  side  of  the  carriage  to  the 
other,  the  head  is  frequently  forcibly  thrown  forwards 
and  backwards,  moving  as  it  were  by  its  own  weight, 
the  patient  having  momentarily  lost  control  over  the 
muscular  structures  of  the  neck.  In  such  cases  the 
patient  complains  of  a  severe  straining,  aching  pain  in 
the  articulations  between  the  head  and  the  spine,  and 


Il8  SPRAINS,   ETC., 

in  the  cervical  spine  itself.  This  pain  closely  resembles 
that  pain  felt  in  any  joint  after  a  severe  wrench  of  its 
ligamentous  structures,  but  is  peculiarly  distressing  in 
the  spine,  owing  to  the  extent  to  which  fibrous  tissue 
and  ligament  enter  into  the  composition  of  the  column. 
It  is  greatly  increased  by  movement  of  any  kind,  how- 
ever shght,  but  especially  by  rotation.  The  pains  are 
greatly  increased  on  pressing  upon  and  on  lifting  up 
the  head,  so  as  to  put  the  tissues  on  the  stretch.  In 
consequence  of  this,  the  patient  keeps  the  neck  and 
head  immovable,  rigid,  looking  straight  forwards — nei- 
ther turning  to  the  right  nor  to  the  left.  He  cannot 
raise  his  head  off  a  pillow  without  the  assistance  of  his 
hand,  or  of  that  of  another  person. 

The  lumbar  spine  is  often  strained  by  railway  colli- 
sions, with  or  without  similar  injury  to  the  cervical  por- 
tion of  the  column,  in  consequence  of  the  trunk  being 
forcibly  swayed  backwards  and  forwards  on  the  pelvis 
during  the  oscillation  of  the  carriage  on  the  receipt  of  a 
powerful  shock.  In  such  cases  the  same  kind  of  pain 
is  complained  of.  There  is  the  same  rigidly  inflexible 
condition  of  the  spine,  with  tenderness  on  external 
pressure,  and  great  aggravation  of  suffering  on  any 
movement,  more  particularly  if  the  patient  bends  back- 
wards. The  patient  is  unable  to  stoop  ;  in  attempting 
to  do  so,  he  always  goes  down  on  one  of  his  knees. 

These  strains  of  the  ligamentous  structures  of  the 
spinal  column  are  not  unfrequently  associated  with  some 
of  the  most  serious  affections  of  the  spinal  cord  that  are 
met  with  in  surgical  practice  as  a  remote  consequence 
of  its  injury. 

They  may  of  themselves  prove  most  serious,  or  even 
fatal.  Thus,  in  Case,  34,  we  have  an  instance  of  loosen- 
ing of  the  cervical  portion  of  the  spinal  column  to  such 
an  extent  that  the  patient  could  not  hold  the  head 
upright  without  artificial  support. 

In  Case  35  we  have  an  example  of  inflammatory 
swelling  developing  around  the  sprained  part  to  such 
an  extent  as  to  compress  the  cord  and  spinal  nerves, 
and  thus  lead  to  paralysis.  And  lastly,  in  Sir  A. 
Cooper's  case,  we  have  an  instance  of  a  sprain  of  the 


OF  THE   SPINE.  II9 

spine   terminating  in  death,   and  a  description  of  the 
post-mortem  appearances  presented  by  this  accident. 

The  prognosis  will  depend  partly  on  the  extent  of 
the  stretching  of  the  muscular  and  ligamentous  struc- 
tures, partly  on  whether  there  is  any  inflammatory 
action  excited  in  them  which  may  extend  to  the  inter- 
ior of  the  spinal  canal. 

As  a  general  rule,  where  muscular,  tendinous,  and 
ligamentous  structures  have  been  violently  stretched, 
as  in  an  ordinary  sprain,  however  severe,  they  recover 
themselves  in  the  course  of  a  few  weeks,  or  at  most 
within  three  or  six  months.  If  a  joint,  as  the  shoulder 
or  ankle,  continues  to  be  weak  and  preternaturally 
mobile,  in  consequence  of  elongation  of  the  ligaments, 
or  weakness  or  atrophy  of  the  muscles,  beyond  this 
period,  it  will,  in  all  probability,  never  again  be  so 
strong  as  it  was  before  the  accident. 

The  same  holds  good  with  the  spine ;  and  a  verte- 
bral column,  which,  as  in  Case  34,  has  been  so  weak- 
ened as  to  require  artificial  support,  after  a  lapse  of 
eleven  months,  in  order  to  enable  it  to  maintain  the 
weight  of  the  head,  will  not,  in  all  probability,  ever 
regain  its  normal  strenth  and  power  of  support. 

In  strumous  or  delicate  constitutions  sprains  or 
wrenches  of  the  spine  will  frequently  lay  the  foundation 
of  serious  organic  disease  of  the  bones  and  articular 
structures,  leading  to  angular  curvature  of  the  spine, 
with  abscess,  paraplegia,  and  possibly  ultimately  a  fatal 
result.  The  following  case  is  one  of  many  that  I  have 
seen  illustrative  of  these  facts. 

Case  33. —  Wrench  of  Spine  in  Hunting — Gradual 
Supervention  of  Angular  Ctirvature — Paraplegia — Par- 
tial Recovery — Second  Accident — Large  Abscesses  and 
Death. — C.  D.,  aged  21,  was  seen  by  me  in  consultation 
with  Mr.  Hey,  of  Leeds,  in  April,  1869.  He  was  a  slen- 
der, active  young  man,  much  given  to  athletic  exercises. 
One  year  previously,  in  April  1868,  whilst  hunting,  his 
horse  suddenly  went  into  a  hole.  The  patient  was 
looking  round  at  the  time,  and,  in  order  to  prevent 
being  thrown,  made  a  violent  effort.  He  felt  at  the 
time  that  he  had  given  himself  a  severe  wrench  in  the 


126  SPRAINS,   ETC., 

left  side,  close  to  the  middle  of  the  back ;  but  no  sign 
of  paralysis,  or  of  any  injury  to  the  nervous  system  was 
manifested.  He  was  obliged,  however,  to  lay  up  for 
some  months,  and  was  kept  quiet  by  order  of  his 
medical  attendants.  In  the  course  of  the  summer  he 
lost  the  pain  at  the  seat  of  injury,  and  gradually  recov- 
ered his  health.  In  the  autumn  he  went  to  Whitby, 
where  he  rode,  played  at  cricket,  ran  races,  danced  ; 
in  fact,  indulged  in  all  those  exercises  and  sports 
that  wxre  natural  to  his  age  and  consonant  with  his 
disposition.  He  continued  much  in  this  state  until 
Christmas,  1868,  when  he  became  rather  suddenly 
paraplegic,  without  pain,  cramps,  or  any  sign  of  menin-' 
geal  or  spinal  irritation.  He  was  obliged  to  lie  by, 
the  paraplegia  of  the  lower  limbs  being  complete. 
When  I  saw  him  at  Ilkley,  in  consultation  with  Mr. 
Hey  and  Dr.  Call,  I  found  that  there  was  complete  loss 
of  motive  power  in  the  lower  extremities ;  sensation 
also  was  greatly  diminished,  if  not  entirely  abolished. 
The  sphincters  were  not  affected  ;  he  passed  his  urine 
voluntarily  ;  it  was  acid.  He  could  not  restrain,  although 
he  could  feel,  the  passage  of  his  emotions.  There  was 
considerable  excurvation  of  the  sixth,  seventh,  and 
eighth  dorsal  vetebrae,  the  seventh  being  very  promi- 
nent. There  was  no  tenderness,  however,  or  sign  of 
abscesses  anywhere.  The  conclusion  that  we  came  to 
was,  that  in  consequence  of  the  wrench  of  the  spine 
there  was  dry  caries  of  the  body  of  the  seventh  dorsal 
vertebra,  and  the  cord  was  compressed  at  this  situation. 
He  was  ordered  small  doses  of  the  perchloride  of  mer- 
cury, caustic  issues  or  the  actual  cautery  to  the  side  of 
the  spine,  the  prone  position,  and  to  take  cod-liver  oil 
and  good  diet.  Under  this  treatment  he  gradually 
recovered.  In  May,  1871,  he  was  able  to  come  up  to 
London.  He  walked  well,  and  was  quite  free  from  all 
paralytic  symptoms.  He  was  able  to  walk  three  or  four 
miles,  could  stand  and  hop  on  one  leg.  He  complained 
of  occasional  spasmodic  and  involuntary  twitches  in  the 
legs,  and  of  some  stiffness  in  one  knee.  There  was  no 
trouble  with  the  bladder  or  rectum,  but  the  bowels 
were  constipated,  and  he  had  loss  of  sexual  desire  and 


OF  THE   SPINE.  121 

power.  The  excurvation  of  the  spine  continued,  but 
there  was  no  tenderness  on  pressure  or  pain  on  moving 
the  vertebral  column.  Unfortunately,  he  was  some 
time  afterwards  thrown  out  of  a  dog-cart,  in  conseqence 
of  which  he  sustained  a  fresh  injury  to  his  spine  ;  an 
abscess,  which  I  opened  in  April,  1873,  developed,  and 
he  eventually  died  in  May  of  the  same  year,  from 
exhaustive  and  irritative  fever,  consequent  upon  exten- 
sive suppuration. 

One  great  prospective  danger  in  sprains  of  the  spine 
is  the  possibility  of  the  inflammation  developed  in  the 
fibrous  structures  of  the  column  extending  to  the  me- 
ninges of  the  cord.  This  I  have  several  times  seen 
occur,  and  I  believe  that  this  happened  in  some  of  the 
cases  I  have  recorded.  We  see  that  this  is  particularly 
apt  to  take  place  when  the  sprain  or  twist  occurs  between 
the  occiput  and  the  atlas  or  axis.  In  these  cases  a  rigid 
tenderness  is  gradually  developed,  which  is  most  dis- 
tressing and  persisting,  and  evidently  of  an  inflamma- 
tory character.  Or,  as  in  Case  31,  the  paralysis  may 
remain  incomplete,  being  confined  to  the  nerves  that  are 
connected  with  that  part  of  the  spine  which  is  the  seat  of 
the  wrench,  one  or  other  of  their  roots  either  having  suf- 
fered lesion,  or  the  nerves  themselves  having  been  injured 
in  their  passage  through  the  intervertebral  foramina. 

Lastly,  in  Sir  A.  Cooper's  case,  a  twist  of  the  spine 
may  slowly  and  insidiously  be  followed  by  symptoms 
of  complete  paraplegia,  and  eventually  by  death  from 
extravasation  of  blood  into  the  vertebral  canal. 

Case  34.  Severe  Strain  of  Cervical  Spine — Paralysis 
of  Left  Arm — Long-continued  Weakness  of  Neck. — Miss 

,  a  lady,  twenty-eight  years  of  age,  was  involved  in 

a  terrible  catastrophe  that  occurred  on  June  9,  1865, 
when,  in  consequence  of  a  bridge  giving  way,  a  portion 
of  a  train  was  precipitated  into  a  shallow  stream.  This 
lady  lay  for  two  hours  and  a  half  under  a  mass  of  broken 
carriages  and  debris  of  the  bridge,  another  lady,  a  fel- 
low-passenger,  who   had   been    killed,  being  stretched 

across  her.     Miss was  lying  in  such  a  position. that 

she  could  not  move.  Her  head  was  forcibly  twisted  to 
the  right  side,  and  the  neck  bent  forwards. 


122  SPRAINS,   ETC., 

When  extricated  she  was  found  to  be  a  good  deal 
cut  about  the  head  and  face,  and  the  left  arm  was 
extensively  bruised,  ecchymosed,  and  perfectly  power- 
less. 

Her  neak  had  been  so  violently  twisted  or  wrenched 

that  for  a  long  time  Miss lost  completely  all  power 

of  supporting  the  head,  which  she  said  felt  loose.  It 
used  to  fall  on  any  side,  as  if  the  neck  was  broken, 
usually  hanging  with  the  chin  resting  on  the  breast. 

Without  going  unnecessarily  into  the  minute  details 
of  all  the  distressing  symptoms  with  which  this  young 
lady  was  affected,  it  will  suffice  to  say  that  she  gradually 
recovered  from  all  her  general  bodily  sufferings,  except 
these  conditions,  viz.,  a  weakened  state  of  the  neck,  a 
loss  of  power  in  the  left  arm,  and  pain  in  the  lower  part 
of  the  back. 

The  neck  had  been  so  severely  twisted  and  sprained 
that  the  ligamentous  and  muscular  structures  seemed 
to  be  loosened,  so  that  in  order  to  keep  the  head  in 
position  she  was  obliged  to  wear  a  stiff  collar  lest  the 
head  should  fall  loosely  from  side  to  side.  At  first  it 
had  a  special  tendency  to  fall  forwards ;  but  after  a 
time  the  tendency  was  in  a  backward  direction.  When 
lying  on  her  back  she  had  no  power  whatever  to  raise 
her  head,  and  to  do  so  was  obliged  to  put  her  right 
hand  under  it  so  as  to  support  it.  If  she  wished  to  get 
up  when  in  bed,  for  instance,  she  assumed  a  most  dis- 
tressing action,  being  compelled  to  roll  over  on  to  her 
face,  and  then,  pressing  her  forehead  against  the  pillow, 
to  get  upon  her  knees. 

There  was  no  pain  in  the  cervical  spine,  nor  could 
any  irregularity  of  the  vertebrae  be  detected.  There 
was  no  pain  in  forcibly  moving  the  head  on  the  atlas, 
or  rotating  this  bone  on  the  axis.  The  looseness 
appeared  to  be  in  the  lower  part  of  the  cervical  spine. 

The  left  arm  at  first  and  for  many  weeks  afterwards 
was  completely  powerless,  all  sensation  as  well  as  power 
of  motion  in  it  having  been  lost.  Sensation  gradually 
and  slowly  returned.  But  the  whole  of  the  nerves  of 
the  brachial  plexus  appeared  to  be  partially  paralyzed, 
so  far  as  motor  influence  was  concerned.     The  circum- 


OF  THE   SPINE.  123 

flex,  the  musculo-spiral,  the  median  and  the  ulnar 
nerves  were  all  affected  to  such  a  degree  as  to  occasion 
great  loss  of  power  to  the  muscles  they  respectively 
supplied.  Thus  she  could  not  use  the  deltoid  so  as  to 
raise  the  arm  to  the  top  of  the  head.  She  could  not 
pick  up  a  pin  or  even  a  quill  between  the  thumb  and 
forefinger.  She  could  not  hold  a  book.  The  power  of 
grasping  with  the  left  hand  and  fingers  was  infinitely 
less  than  that  with  the  right,  and  there  was  some  rigid 
contraction  of  the  little  and  ring  fingers.  The  muscles 
of  the  left  hand  and  of  the  ball  of  the  thumb  were 
wasted. 

This  crippled  and  partially  paralyzed  state  of  the  left 
arm  was  a  most  serious  and  distressing  inconvenience  to 
the  patient.  Before  the  accident  she  had  been  an 
intrepid  rider,  a  skilful  driver,  and  an  accomplished 
musician,  playing  much  on  the  harp  and  piano.  All 
these  pursuits  were  necessarily  completely  put  a  stop 
to,  and  from  being  remarkable  for  her  courage  she  had 
become  so  nervous  that  she  scarcely  dared  to  ride  in  a 
carriage. 

Mr.  Tapson  had  most  skilfully  and  assiduously 
attended  this  very  distressing  case  almost  from  the 
time  of  the  accident,  and  the  patient  had  occasionally 
had    the    advantage    of    Mr.    Holmes    Coot's    advice. 

When    I    saw    Miss   in    consultation   with    these 

gentlemen  on  April  20,  1866,  ten  and  a  half  months 
after  the  accident,  they  told  me  that  the  condition  of 
the  neck  had  certainly,  though  very  slowly,  improved, 
but  that  the  state  of  the  left  arm,  which  was  such  as 
has  just  been  described,  had  undergone  no  change  for 
several  months. 

The  pain  in  the  lower  part  of  the  back  had  increased 
during  the  last  two  months.  There  was  no  disturbance 
of  the  mind,  and  no  sign  of  cerebral  irritation.  The 
bodily  health  generally  was  fairly  good — as  much  so  as 
could  be  expected  under  the  altered  circumstances  of 
life  that  this  accident  had  in  so  melancholy  a  manner 
entailed  on  this  young  lady. 

The  state  of  the  cervical  spine  in  this  case  was  most 
remarkable.     It  was  movable   at  its  lower  part  in   all 


124  SPRAINS,   ETC., 

directions,  as  if  it  were  attached  to  a  universal  joint,  or 
had  a  ball-and-socket  articulation,  the  weight  of  the 
head  carrying  it  in  all  directions.  It  was  almost  impos- 
sible to  conceive  so  great  a  degree  of  mobility  existing 
without  dislocation — but  there,  was  certainly  neither 
luxation  nor  fracture,  the  vertebrae  being  apparently 
loosened  from  one  another  in  their  ligamentous  connec- 
tions and  their  muscular  supports,  so  that  the  weight  of 
the  head  was  too  great  for  the  weakened  spine  to  carry. 
This  loosening  was  most  marked  in  the  lower  cervi- 
cal region,  and  did  not  exist  between  the  atlas  and  the 
occiput.  It  was  clearly  the  direct  result  of  the  vio- 
lent and  long-continued  wrench  to  which  this  part  of 
the  spine  had  been  subjected. 

The  paralysis  was  confined  to  the  left  arm,  no  other 
part  of  the  body  having  been  affected  by  it.     At   first 
the  paralysis  was  complete,  the  arm  being  perfectly  pow- 
erless and  sensation  being  quite  lost.     After  a  time  sen- 
sation returned,  but  motion  was  still  very  imperfect, 
and  no  improvement  had  taken  place  in  this  respect  for 
several   months.     As  the  nerves  of  the  whole  of  the 
brachial  plexus  were  implicated,  and  apparently  to  the 
same  degree,  it  was  difficult  to  account  for  this  in  any 
other  way  than  by  an  injury  inflicted  upon  them  at 
their  origin  from  the  cord,  or  in  their  exit  through  the 
vertebral  column.     I  think  it  most  probable  that  this 
latter  injury  was  the  real  cause  of  nervous  weakness  to 
the  left  arm,  for  the  spine  had  been  wrenched  in  the 
lower  cervical  region,  in  that  part,  in  fact,  which  corre- 
sponds to  the  origin  of  the   brachial  plexus,  and  there 
was  not  at  the  time  of  my   visit,  nor  did  the  re  appear 
to  have  been,  at  any  previous  period,  any  disturbance 
in  the  functions  of  the  spinal  cord  as  a  whole  ;  the  par- 
alysis  being   entirely   and  absolutely  localised  to  the 
parts  supplied  by  the  left  brachial  plexus,  implicating 
these  only  so  far  as  motor  power  was  concerned,  and 
affecting  no  other  portion  of  the  nervous  system. 

Case  35. — Fall  on  the  Head — Tzvist  of  Cervical  Spine 
— Gradual  Paralysis  of  the  Whole  of  Body — Slozv  Recov- 
ery.— The  following  case,  which  I  have  seen  several 
times  in  consultation  with  Dr,  Russell  Reynolds,  under 


OF   THE   SPINE.  125 

whose  immediate  care  the  patient  was,  and  to  whom  I 
am  indebted  for  its  early  history,  affords  an  excellent 
illustration  of  some  of  the  effects  that  may  result  from 
a  severe  twist  or  wrench  of  the  spine. 

Mr.  G.,  about  23  years  of  age,  a  strong,  well-formed, 
healthy  young  man,  was  thrown  from  his  horse  on 
December  12th,  1865.  He  fell  on  the  back  of  his  head, 
on  soft  ground,  and  rolled  over.  He  got  up  immedi- 
ately after  the  fall  and  walked  to  his  house,  a  distance 
of  about  one  hundred  yards.  He  had  no  cerebral  dis- 
turbance whatever,  being  neither  insensible,  delirious, 
concussed,  nor  sick.  The  head  was  twisted  to  the  left 
side,  and  he  felt  pain  in  the  neck.  He  kept  his  bed  in 
consequence  of  this  pain  in  the  neck  till  January  ist, 
1866,  and  his  room  for  a  week  longer.  At  this  time  he 
tried  to  write,  but  found  great  difficulty  in  controlling 
his  right  arm.  He  managed,  however,  to  do  so,  and 
did  write  a  letter.  He  was  under  surgical  treatment  in 
the  country,  and  was  not  considered  to  have  paralysis, 
as  he  could  use  his  arms  well  for  all  ordinary  purposes, 
and  could  walk  without  difficulty. 

Towards  the  end  of  January,  nearly  six  weeks  after 
the  accident,  symptoms  of  paralysis,very  gradually  and 
slowly  began  to  develop  themselves.  The  right  arm 
became  cold,  numb,  and  was  affected  by  creeping  sensa- 
tions. His  right  leg  became  weak,  unequal  to  the  sup- 
port of  the  body,  and  he  dragged  his  right  foot. 

He  came  to  town  on  February  21st,  when  he  was 
seen  for  the  first  time  by  Dr.  Reynolds,  who  reports 
that  at  this  period  the  paralysis  of  the  right  arm  had 
become  complete,  while  that  of  the  right  foot  was  par- 
tial, the  patient  walking  with  a  drag  of  the  foot.  His 
limbs  gave  way  under  him,  so  that  he  had  occasionally 
fallen.  He  had  no  pain  in  any  part  of  the  body ;  his 
mind  was  clear,  but  he  was  very  restless. 

On  the  27th  of  February,  whilst  stooping,  he  fell  in 
his  bedroom,  struggled  much,  and  was  unable  to  rise. 
He  was  found,  after  a  time,  lying  partly  under  his  bed. 
On  the  following  day,  it  was  found  that  the  left  side 
was  partially  paralysed,  the  right  side  continuing  in  the 
condition  already  described.     There  was  now  consider- 


126  SPRAINS,   ETC., 

able  swelling  and  tenderness  on  the  left  side  of  the 
neck  and  about  the  third  and  fourth  cervical  vertebrae. 
He  was  seen  shortly  after  this  by  Sir  William  Jenner, 
in  consultation  with  Dr.  Reynolds,  and  was  ordered 
complete  rest,  with  large  doses  of  the  iodide  of  potas- 
sium. 

I  saw  him  on  March  3d,  in  consultation  with  Dr. 
Reynolds.  I  found  him  lying  on  his  back  in  bed.  The 
mind  quite  clear  ;  spirits  good.  No  appearance  of  anx- 
iety or  distress  in  the  countenance ;  in  fact  I  was  much 
struck  by  the  happy,  cheerful  expression  of  his  coun- 
tenance under  the  melancholy  circumstances  in  which 
he  was  placed. 

I  found  his  condition  much  as  has  been  described. 
There  was  complete  paralysis  of  the  right  arm  and  par- 
tial paralysis  of  the  right  leg.  The  left  arm  was  also 
partially  paralysed,  and  the  left  leg  slightly  so.  He  was 
unable  to  stand.  There  was  no  affection  of  the  blad- 
der or  of  the  sphincter  ani.  The  skin  was  hot  and  per- 
spiring ;  the  pulse  quick ;  the  urine  acid. 

He  could  not  raise  his  head  off  the  pillow,  and  lay 
quite  flat  on  his  back.  On  being  raised  up  in  the  sitting 
posture,  it  was  necessary  to  support  his  head  with  the 
hands  ;  and  when  he  was  seated  upright,  he  held  the 
head  firmly  fixed,  the  spine  being  kept  perfectly  rigid. 
He  was  quite  unable  to  turn  or  move  the  head. 

The  back  part  of  the  neck  was  swollen,  especially  on 
the  left  side,  and  was  tender  on  pressure.  The  swelling 
was  less  than  it  had  been.  The  cervical  vertebrae  felt 
as  if  they  were  somewhat  twisted,  so  that  the  head 
inclined  towards  the  right  side.  It  was  doubtful 
whether  this  was  really  so.  The  patient  continued  the 
iodide  of  potassium,  and  a  gutta  percha  case,  extending 
from  the  top  of  his  head  to  the  pelvis,  and  embracing 
the  shoulders  and  back  of  the  chest,  was  moulded  on 
him,  so  as  to  keep  the  head  and  spine  motionless.  He 
was  ordered  to  lie  on  his  back,  and  not  to  move. 

I  saw  the  patient  several  times  with  Dr.  Reynolds, 
and  we  were  gratified  to  find  that  a  steady  improvement 
was  taking  place.  On  March  27th,  he  had  completely 
lost  all  symptoms  of  paralysis  on  the  left  side  of  the 


OF  THE   SPINE.  12^ 

body ;  the  right  leg  had  recovered  its  power,  and  the 
paralytic  symptoms  had  almost  entirely  disappeared 
from  the  right  arm.  He  could  raise  it,  grasp  with  his 
hand,  and  in  fact  use  it  for  the  ordinary  purposes  of 
life.  He  could  stand,  though  in  a  somewhat  unsteady 
way.  This  seemed  owing  rather  to  his  having  kept  the 
recumbent  position  for  so  long  a  time  thar  to  any  loss 
of  nervous  power  in  the  legs. 

The  swelling  of  the  neck  had  entirely  subsided,  and 
the  cervical  spine  was  straight,  but  it  was  rigid,  and  he 
could  not  turn  the  head.  The  support  was  habitually 
worn,  and  gave  him  great  comfort. 

This  case  is  remarkable  in  several  particulars.  In 
the  first  place,  the  fact  that  the  paralysis  did  not  begin 
to  show  itself  until  many  weeks — nearly  six — had 
elapsed  from  the  time  of  the  accident  is  a  matter 
of  the  greatest  consequence  in  reference  to  these 
injuries.  Then  again,  the  fact  that  although  the  brain 
was  throughout  unaffected,  and  the  injury  purely 
spinal,  the  paralysis  was  of  a  hemiplegic  and  not  a 
paraplegic  character,  is  also  not  without  import.  And 
lastly,  the  gradual  subsidence  of  the  very  threatening 
symptoms  with  which  the  patient  was  affected,  and  the 
disappearance  of  the  paralysis  of  the  limbs  in  the 
inverse  order  to  that  in  which  it  developed  itself  in 
them,  should  be  observed. 

That  wrenches  or  twists  of  the  spine  may  slowly 
develop  paralytic  symptoms,  and  may  be  attended 
eventually  by  a  fatal  result,  is  well  illustrated  by  a  case 
recorded  by  Sir  Astley  Cooper  as  occurring  in  the  prac- 
tice of  Mr.  Heaviside.  It  is  briefly  as  follows: — A  lad, 
12  years  old,  whilst  swinging  in  a  heavy  wooden  swing, 
was  caught  under  the  chin  by  a  rope,  so  that  his  head 
and  the  v/hole  of  the  cervical  vertebrae  were  violently 
strained.  As  the  rope  immediately  slipped  off,  he 
thought  no  more  of  it.  For  some  months  after  the 
occurrence  he  felt  no  pain  or  inconvenience,  but  it  was 
observed  that  he  was  less  active  than  usual,  and  did  not 
join  in  the  games  of  his  schoolfellows.  At  that  time 
it  was  found  that  he  was  really  weaker  than  before  the 
accident.     He  suffered  from  pains  in  the  head  and  in 


128  SPRAINS,    ETC., 

the  back  of  the  neck,  the  muscles  of  which  part  were 
stiff,  indurated,  and  very  tender  to  external  pressure. 
Movement  of  the  head  in  any  direction  gave  rise  to 
pain,  and  there  was  diminution  in  voluntary  power  of 
motion  in  his  limbs. 

Eleven  months  after  the  accident  the  paralytic  affec- 
tion of  the  limbs  was  gradually  getting  much  worse,  in 
addition  to  which  he  felt  a  most  vehement  and  burning 
pain  in  the  small  of  his  back.  His  symptoms  gradu- 
ally became  worse,  difficulty  of  breathing  set  in,  and  he 
died  exactly  twelve  months  after  the  accident. 

On  examination  after  death  the  whole  contents  of 
the  head  were  found  to  be  perfectly  healthy.  There 
was  no  fracture  or  other  sign  of  injury  to  the  spine, 
but  "  the  theca  vertebralis  was  found  overflowing  with 
blood  which  was  effused  between  the  theca  and  the 
inclosing  canals  of  bone.  The  effusion  extended  from 
the  first  vertebra  of  the  neck  to  the  second  vertebra  of 
the  back,  both  included."'" 

This  case  is  a  most  valuable  one.  It  illustrates  one 
of  the  important  points  in  that  last  described,  viz.,  the 
very  slow,  gradual,  and  progressive  development  of 
paralysis  in  these  injuries  of  the  spine.  And  as  it  was 
attended  by  a  fatal  issue  and  the  opportunity  of  a  post- 
mortem examination,  it  also  proves  that  this  slow  and 
progressive  development  of  paralysis  after  an  interval 
of  "  some  months  "  may  be  associated  with  extensive 
and  serious  lesion  within  the  spinal  canal,  with  the 
effusion,  in  fact,  of  a  large  quantity  of  blood  upon  the 
membranes  of  the  cord, — the  very  condition  that  has 
already  been  shown  to  be  the  common  accompani- 
ment of  many  fatal  cases  of  so-called  "  Concussion  of 
the  Spine." 

Each  of  these  cases  of  twist  of  the  spine  is  typical 
of  a  special  group  of  these  injuries.  In  the  first  we 
have  sudden  and  immediate  paralysis  of  one  arm  pro- 
duced by  the  wrench  to  which  that  portion  of  the  spine 
that  gives  exit  to  the  nerves  supplying  that  limb  had 
been  subjected. 

*  Sir  A.  Cooper,  "  Fracture  and  Dislocations,"  8  vo,  ed.,  p.  53O. 


OF  THE   SPINE. 


129 


In  the  second  we  have  paralysis,  resulting  after  an 
interval  of  some  weeks,  as  a  consequence  of  the  pres- 
sure of  the  secondary  inflammatory  effusions  that  had 
been  slowly  produced  by  the  injury  to  the  spine  and  its 
contents, — that  paralysis  disappearing  as  these  effusions 
were  absorbed. 

In  the  third  case  we  have  an  instance  of  death 
resulting  in  twelve  months  after  a  wrench  of  the  spine 
by  the  effects  of  haemorrhage  into  the  spinal  canal. 

The  following  cases  will  illustrate  many  of  the 
points  to  which  I  have  drawn  special  attention  in  this 
Lecture.  \. 

I  saw  the  following  case  in  November,  1866,  in  the 
London  Hospital.  It  illustrates  well  the  rapid  super- 
vention of  Paraplegia  from  a  twist  or  wrench. 

Case  36. — Sudden  Tzvist  of  Spine — Paraplegia. — J. 
H.,  aged  44,  an  iron  founder,  six  weeks  before,  whilst 
standing  in  a  constrained  attitude  inside  the  mould  of 
a  casting,  and  engaged  in  throwing  out  some  heavy 
shovelfuls  of  sand  in  a  way  that  required  much  twist- 
ing of  the  body,  suddenly  experienced  a  sensation  in 
his  back  which  he  likened  to  a  snap  of  the  fingers.  He 
did  not  fall  down  but  was  able  to  continue  his  work 
till  the  evening  without  difficulty,  although  he  said  that 
about  an  hour  after  the  event  he  was  walking  home, 
and  felt  a  ''swimminess  "  in  his  legs  for  a  moment,  and 
as  if  he  would  fall.  He  went  to  bed  early  in  the  even- 
ing, and  when  he  tried  to  get  up  the  following  morning, 
he  found  he  had  lost  all  power  over  his  legs  and  all 
sensation  in  them,  being  unable  to  rise  out  of  bed  or  to 
stand,  which  he  had  not  been  able  to  do  since.  Faeces 
and  urine  passed  involuntarily  and  without  his  knowing 
it.  There  was  now  no  power  of  motion  in  either  foot, 
reflex  movements  were  also  absent  ;  sensation  was 
absent  in  both  legs  and  in  the  trunk  to  about  the  level 
of  the  umbilicus.  On  the  inner  side  of  the  sole  of  the 
left  foot,  however,  he  could  still  feel.  The  left  arm,  he 
said,  became  numb  if  he  let  it  remain  still  for  any 
length  of  time.  Its  temperature  was  about  half  a 
degree  lower  than  that  of  the  right. 

The  urine  was  alkaline,  had  a  very  ammoniacal  odor, 

9 


130  SPRAINS,   ETC 

effervesced  strongly  on  the  addition  of  nitric  acid,  had 
a  deposit  which  disappeared  partly  on  the  addition  of 
nitric  acid  (phosphates) ;  the  part  which  did  not  dis- 
solve having  the  appearance  of  mucus. 

There  was  no  pain  on  pressing  the  hand  down  the 
vertebral  column. 

He  left  the  hospital  at  the  end  of  the  following 
March.  Mr.  Adams  kindly  informed  me  that  there  was 
not  much  improvement  in  his  paralysis.  He  was,  how- 
ever, just  able  to  move  his  toes  and  feet  very  slightly, 
but  was  utterly  unable  to  stand.  His  water  dribbled 
away,  and  his  faeces  passed  involuntarily,  though  with 
some  irritation. 

The  next  case  is  a  very  similar  one  of  rapid  super- 
vention of  paraplegia,  after  a  strain  of  the  spine  in  a 
railway  accident. 

Case  37. —  Wrench  of  Spine  from  Railway  ^Accident — 
Symptoms  not  Immediate — Par ap leg  ia — Phlebitis — Even- 
tual Recovery. — Miss  A.  B.,  aged  22,  a  young  lady  of 
remarkable  personal  beauty,  tall,  strong,  and  well 
formed,  in  excellent  health,  who,  to  use  her  own  expres- 
sion, could  '*  ride  all  day  and  dance  all  night,"  without 
feeling  fatigued,  met  with  the  following  accident. 

Whilst  travelling  on  the  London  and  North  West- 
ern Railway,  on  December  26,  1865,  the  carriage  in 
which  she  was  seated  came  into  collision  with  some 
obstruction  on   the   line   and  Avas   turned  over.     Miss 

was  violently  shaken,  bruised  about  the  knees  and 

legs,  but  received  no  blow  upon  the  body.  She  felt  a 
sudden  wrench  or  twist  in  the  lower  part  of  the  spine, 
and  according  to  the  statement  of  her  fellow-passengers, 
called  out,  *'  Oh  !  my  back  is  broken  !  "  She  was,  how- 
ever unconscious  of  the  exclamation.  After  being  extri- 
cated from  the  overturned  carriage,  she  was  able  to 
walk,  and  sat  down  upon  the  embankment,  feeling  no 
pain,  but  rather  stiff.  In  the  evening  she  found  a  diffi- 
culty in  moving  the  legs.  The  next  morning  she  was 
unable  to  stand,  and  from  that  time  she  Avas  paralyzed 
in  both  lower  extremities.  The  paralysis  was  almost 
complete  so  far  as  motion  was  concerned.  The  only 
motor  power  left  consisted  in  moving  the  toes  to  a  lim- 


OF  THE   SriNE.  I3I 

ited  extent,  and  the  foot  or  the  ankle  very  sHghtly. 
She  could  not  raise  either  Hmb,  nor  had  she  the  sHght- 
est  power  of  supporting  herself  or  standing.  Sensation 
was  little  if  at  all  impaired,  but  there  was  rigidity  of 
the  muscles  of  the  legs.  The  pelvic  organs  were  not 
affected. 

There  was  severe  pain  on  pressure  and  on  movement, 
opposite  the  second  and  third  lumbar  vertebrae,  especially 
if  the  body  was  bent  backwards.  The  pain  extended 
towards  the  left  side  of  the  pelvis,  but  existed  nowhere 
else. 

About  six  weeks  after  the  accident,  the  veins  of  the 
left  thigh  became  obstructed  by  thrombosis,  the  limb 
swelled  and  became  oedematous,  and  the  general  health 
suffered  very  seriously. 

This  young  lady  was  seen  by  several  surgeons.  The 
treatment  that  was  adopted  was  chiefly  complete  rest 
on  a  couch,  and  alterative  and  tonic  medicines.  She 
continued  in  much  the  same  state,  with  little  if  any 
change  in  the  symptoms,  until  October,  1866,  when  she 
came  more  completely  under  my  care  than  she  had  pre- 
viously been.  I  now  ordered  her  repeated  blistering  to 
the  tender  part  of  the  spine,  and  put  her  on  a  course  of 
small  doses  of  the  perchloride  of  mercury  in  bark. 
Under  this  plan  of  treatment  she  began  to  improve,  so 
much  so  that  she  could  bend  the  knees,  draw  up  the 
legs,  and  move  the  feet  more  freely. 

In  the  early  part  of  1867  a  spinal  support  was  fitted 
on,  so  as  to  remove  pressure  from  the  spine  and  uphold 
the  trunk.  The  blistering  was  continued,  and  iron  and 
strychnine  substituted  for  the  other  remedies. 

She  was  sent  to  Brighton,  where  for  months  she  was 
confined  to  the  recumbent  position,  but  was  taken  as 
much  as  possible  into  the  open  air  on  a  wheel  couch. 
This  treatment  was  continued  till  February,  1867,  when 
she  was  able  to  sit  up,  and  a  few  months  later  to  stand 
upright  by  leaning  on  the  back  of  a  chain  From  this 
time  she  slowly  but  progressively  recovered.  By  July, 
1868,  she  was  quite  well,  and  has  remained  so  ever 
since.  I  give  the  next  two  cases  in  cxtenso^  as  taken 
from  the  Hospital  Case  Books. 


132  SPRAINS,    ETC., 

Case  38.  Severe  Wrench  of  Cervical  Spine— Paraly- 
sis— Recovery. — W.  H.,  aged  22,  London,  admitted  into 
University  College  Hospital,  November  21,  1868.  The 
patient  had  the  same  day  fallen  out  of  the  front  of  a 
van,  and  was  ''  rolled  up  by  the  axle,"  though  the  wheel 
did  not  pass  over  him.  He  did  not  feel  much  pain,  but 
experienced  a  strain  or  twinge  at  the  lower  part  of  the 
neck  behind.  He  was  carried  away  quite  sensible  to  the 
hospital,  not  feeling  pain  but  numbness,  extending  down- 
wards from  the  lower  hinder  part  of  the  neck  to  the  feet. 

On  admission  the  patient  was  perfectly  conscious. 
He  had  lost  all  sensation  in  his  arms,  legs,  and  in  the 
trunk  below  the  third  rib.  His  limbs  were  powerless. 
When  the  patient  was  put  in  bed  and  his  neck  exam- 
ined, there  was  great  tenderness  on  pressure  over  the 
the  (?)  fourth  cervical  vertebra ;  in  this  situation  there 
was  unusual  prominence.  There  was  retention  of  the 
urine,  and  paralysis  of  the  sphincters.  Patient  was  put 
on  a  mattress,  his  head  on  same  level  as  his  body.  A 
catheter  was  passed. 

Nov.  22d. — Patient  can  move  his  right  leg  about,  also 
his  left  arm,  but  the  right  arm  only  slightly.  Cannot 
clench  his  fist.  Deficient  sensibility  in  his  limbs  and 
trunk.  Ordered  a  simple  enema,  which  was  retained. 
The  deltoid  and  biceps  of  the  right  arm  act,  but  the 
triceps  and  muscles  of  the  forearm  and  hand  do  not. 
The  flexors  and  extensors  of  the  arm,  and  the  exten- 
sors of  the  forearm  of  the  left  side  act,  but  the  other 
muscles  are  useless. 

23d. — Sensation  not  yet  natural,  his  chief  pain  is  in 
his  right  shoulder.  When  he  moves  his  head  he  has 
pains  shooting  down  the  legs  and  right  arm.  Complains 
of  tingling  in  the  thumb  and  two  outer  fingers  of  both 
hands,  extending  towards  the  wrist.  In  the  other  fin- 
gers there  is  numbness. 

24th. — Great  pain  is  caused  if  the  right  arm  is 
brought  forwards  over  the  chest,  and  there  is  semi-pri- 
apism. 

Back  of  patient  beginning  to  feel  sore. 

A  large  splint  was  applied  to  the  back  to  support  his 
head. 


OF  THE   SPINE.  1 33 

25th. — Patient  feels  better.  Total  loss  of  voluntary 
power  in  lower  extremities.  Some  slight  reflex  action 
on  tickling  the  soles  of  his  feet.  Complains  of  hot  sen- 
sations running  down  his  right  arm.  The  back  is  get- 
ting worse,  and  a  bed-sore  is  forming. 

26th. — Last  night  patient  had  an  enema.  This  was 
retained.  This  morning  had  one  ounce  of  castor-oil. 
His  bowels  were  freely  opened  and  he  felt  better. 

No  return  of  voluntary  motion  in  the  legs. 

28th. — Patient  is  able  to  move  his  legs  very  slightly, 
raises  his  knees  a  little  off  the  bed  ;  right  more  than 
left.  If  he  moves  his  head,  the  same  shooting  pains 
are  still  felt  in  the  right  arm.  He  complains  most  of 
his  back.     Was  put  on  an  air-bed  to-day. 

29th. — Patient  moves  his  right  arm  more  easily. 
Extension  is  gradually  getting  easier.  Voluntary 
motion  has  increased  in  left  arm. 

30th. — Voluntary  motion  has  improved  in  the  legs. 
He  can  raise  the  knees  better ;  right  more  than  left. 
Sensibility  has  improved. 

Dec.  2d. — Yesterday  an  enema  was  ordered,  and  not 
retained.  Patient  can  now  flex  the  hip  and  knees  to  a 
considerable  extent.  Can  also  move  the  left  leg,  but 
not  to  the  same  extent. 

Cannot  pass  his  urine  yet. 

The  priapism  is  subsiding.  There  is  pain  in  the 
lower  part  of  the  abdomen. 

4th. — Patient  has  gradually  regained  the  power  of 
moving  his  legs. 

To-day,  for  the  first  time,   his  urine  contained  blood. 

6th. — Haemorrhage  from  the  bladder  still  continues, 
though  to  a  less  extent. 

Incontinence  of  urine  is  now  present. 

loth. — Mobility  of  lower  extremities  and  arms,  more 
especially  the  left,  improving. 

Incontinence  of  urine  still  continues. 

Haemorrhage  less. 

nth. — Patient  quite  conscious  of  his  water  passing 
away  from  him.     Other  symptoms  the  same. 

1 2th. — On  account  of  the  great  spasm  caused  by  the 
passage   of  the   catheter,   morphia  had   to  be   injected 


134  SPRAINS,   ETC., 

hypodermically  to  relieve  it,  and  this  it  did  effectually. 
This  also  relieves  the  pain  at  the  lower  part  of  the 
abdomen. 

13th. — Morphia  injection  still  used  before  washing 
out  the  bladder. 

17th. — Up  to  to-day  the  bladder  has  been  washed 
out  every  other  day. 

The  urine  has  gradually  improved ;  it  is  of  its 
natural  color  to-day.  The  haemorrhage  has  ceased. 
Patient  can  now  retain  his  water  for  a  short  time,  a 
quarter  to  half  an  hour,  and  is  beginning  to  regain  the 
power  of  passing  his  urine  to  a  slight  extent.  Still 
some  incontinence. 

1 8th. — Bladder  washed  out  after  a  previous  hypoder- 
mic injection  of  morphia.  Partial  control  over  the 
sphincters  of  the  bladder  and  anus.    No  pain  anywhere. 

19th. — Patient  can  now  move  right  leg  freely.  Less 
movement  of  left,  for  although  he  can  adduct  the 
thigh  he  cannot  flex  the  hip. 

His  urine  has  always  been  very  fetid,  alkaline,  and 
full  of  mucus. 

23rd. — Patient  has  some  pain  at  the  lower  part  of 
the  abdomen.     Urine  the  same. 

24th. — Pain  in  abdomen  has  increased..  Bowels  con- 
fined.    Tongue  furred. 

26. — Pain  somewhat  better  in  abdomen.  Bowels 
open  last  night ;  very  constipated. 

This  morning  the  urine  is  not  so  fetid. 

His  general  condition  to-day  is : — Partial  paralysis 
of  the  right  arm.  The  movements  of  this  limb  being 
slight  attempt  at  supination  ;  the  arm  being  always  kept 
pronated  on  his  chest,  he  can  just  raise  the  hand  off 
the  chest  and  then  twist  it  round  till  it  attains  the  per- 
pendicular ;  he  cannot  supinate  it  more  than  that. 
Any  attempt  to  extend  the  arm  passively  or  to  supi- 
nate it  forcibly  gives  him  pain. 

The  left  leg  is  in  a  similar  condition  to  the  arm ;  he 
can  draw  his  leg  and  thigh  up,  but  he  cannot  raise  his 
heel  off  the  bed.  The  constant  irritation  of  the  urine 
about  the  scrotum  has  made  this  red  and  excoriated. 
The  bed-sore  on  the  back  is  getting  better. 


OF   THE   SPINE.  1 35 

9  P.  M.  Patient  has  been  very  merry,  and  felt  free 
from  pain  all  day,  but  now  he  is  in  a  low,  depressed, 
semi-hysterical  state,  his  pulse  beating  quickly  and 
jerking.  On  enquiring  into  the  cause  of  this,  he  said 
that  he  had  just  been  dreaming  how  he  was  placed  on 
a  board  very  nicely  balanced  on  the  parapet  of  Water- 
loo Bridge,  and  he  was  making  most  violent  efforts  to 
save  himself  when  he  woke  up.  He  says  that  since  the 
accident  he  is  very  subject  to  these  horrid  dreams, 
which  generally  leave  him  in  the  state  he  was  then 
found.  The  pain  at  the  lower  part  of  the  abdomen  is 
worse.  Bowels  confined.  Skin  hot.  Tongue  dry, 
furred ;    great    thirst.     Temperature    ioo° ;  pulse    lOO. 

31st. — Urine  decidedly  improving;  not  so  thick  or 
fetid  as  it  has  been.     Patient  can  hold  his  water  better. 

The  paralysis  has  not  materially  improved  ;  bed-sore 
nearly  well. 

Temperature  9  P.  M.  98.5  (between  thigh  and  scro- 
tum).    Appetite  very  good. 

Jan.  7th. — Patient  has  materially  improved  since  last 
report ;  so  far  as  the  urine  is  concerned,  this  is  not 
fetid,  or  very  little  so.  No  mucus  in  it  except  when 
drawn  off  with  a  catheter,  then  the  last  drops  contain 
a  few  shreds  of  mucus ;  no  blood. 

He  can  hold  his  water  for  two  hours  at  a  time.  The 
bladder  only  requires  to  be  washed  out  every  other 
day,  and  sometimes  only  every  fourth  day.  He  still 
has  the  spasms  when  the  catheter  is  introduced. 

He  can  raise  his  left  heel  a  little  (i  in.)  off  the  bed. 
Sensation  almost  equal  in  both  legs.  On  the  inner  side 
of  the  left  tibia  is  a  small  neuroma  about  the  size  of  a 
cherry-stone.  It  came  on  some  years  ago,  after  a  cut 
on  the  leg.  The  tumor  is  just  about  half  an  inch 
above  the  cicatrix  of  the  wound.  It  is  somewhat  ten- 
der on  pressure,  not  painful  otherwise. 

He  can  move  his  head  about  without  pain.  There 
is  no  tenderness  over  the  seat  of  injury  in  the  neck. 

His  general  appearance  has  undergone  a  change  for 
the  better,  he  looks  more  cheerful,  and  is  getting 
stronger  and  stouter. 

Feb.    13th. — Patient   can   now   move   his  legs  about 


136  SPRAINS,   ETC., 

quite  freely,  and  when  he  extends  the  knees  forcibly  I 
cannot  bend  them  ;  the  same  with  the  ankle.  There  is 
therefore  very  marked  improvement  so  far. 

He  uses  his  arms  quite  freely,  the  right  is  still  weaker 
than  the  left. 

Sensibility  restored  over  whole  body. 

Reflex  action  perfect  in  both  legs. 

The  bladder  has  very  much  improved,  although  not 
so  much  as  the  legs.  He  can  now  hold  his  water  for 
several  hours.  Catheterism  is  no  longer  required,  and 
the  urine  is  perfectly  normal. 

He  can  sit  up  in  bed  without  support,  but  does  not 
get  out  of  bed  yet. 

His  bedsore  is  quite  well. 

Appetite  good  ;  bowels  regular ;  tongue  clean. 

March  3rd. — Patient  allowed  to  get  up  for  the  first 
time  to-day,  still  wearing  the  apparatus.  He  can  now 
walk  with  assistance ;  can  move  his  head  and  neck 
freely.  Sensation  is  complete.  Motion  and  power  in 
the  arms  perfect.  No  pain  or  other  abnormal  sensa- 
tions. Urine  normal.  Micturition  still  somewhat  fre- 
quent. 

Some  phosphatic  deposits  having  formed  in  the  blad- 
der, these  were  removed  by  the  dissolvents,  to  the 
great  comfort  and  advantage  of  the  patient. 

From  this  time  he  gradually  but  slowly  improved. 
He  was  made  an  out-patient,  and  continued  to  attend 
the  Hospital  for  the  next  three  or  four  years,  very 
slowly  mending.  When  suffering  from  a  relapse,  he 
always  came  to  ask  for  a  bottle  of  the  perchloride  of 
mercury.  When  I  last  saw  him,  about  a  year  ago  and 
five  years  from  the  time  of  the  accident,  he  was  fairly 
well ;  able  to  do  light  work,  and  walk  moderately ;  but 
he  suffered  from  headaches  and  weakness  of  the  limbs. 

Case  39. —  Wrench  of  Spine — Relief — Relapse — htcur- 
able  Meningo-Myelitis. — J,  H.,  aged  28,  shipwright  at 
Sheerness,  admitted  into  University  College  Hospital 
May  4,  1867.  Patient  was  a  tall,  well-built  man,  some- 
what worn-looking  and  emaciated,  but  not  greatly  so. 
He  stated  that  he  was  stout  and  very  well  before  the 
accident. 


OF   THE   SPINE.  137 

On  April  15,  patient,  with  three  other  men,  was 
carrying  a  beam  (20  ft.  long  by  9  in.  square).  The  two 
men  at  the  farther  end  let  it  fall  suddenly,  so  that  H. 
and  his  mate  had  to  support  most  of  its  weight,  and 
received  a  violent  jar,  but  no  blow.  Being  the  taller  of 
the  two  men,  he  received  most  of  the  shock.  He  felt 
faint  at  the  time,  but  did  not  fall.  He  walked  home  at 
once  (about  a  quarter  of  a  mile).  Soon  after  he  got 
home  he  felt  severe  pain  in  the  lower  dorsal  region  and 
all  round  the  upper  part  of  the  abdomen.  It  hurt  him 
to  breathe.  At  the  back  of  his  head  he  had  a  severe 
stabbing  pain.  For  four  days  he  had  retention  of  urine 
(which  was  very  thick),  and  he  passed,  for  a  few  days, 
occasional  clots  of  blood  in  his  stools.  Two  days  after 
the  accident  he  had  a  numb  feeling  in  his  legs  below 
the  knees,  and  a  feeling  of  coldness  in  the  calves,  but 
he  had  always  been  able  to  move  his  legs.  States  that 
his  urine  and  motions  used  to  escape  involuntarily. 

The  treatment  had  been  expectant.  Liniments  and 
rest,  no  cupping  or  blisters. 

On  admission  patient  stated  that  he  suffered  from 
giddiness,  and  had  shooting  pains  up  the  back  to  the 
occiput.  He  could  not  see  so  well  as  previously ;  on 
reading,  the  letters  ''  jumped  about,"  and  specks,  black 
and  white,  always  floated  before  his  eyes.  Hearing  and 
speech  unaffected. 

On  examination  the  spine  was  found  to  be  exceedingly 
tender  on  pressure,  from  the  ninth  dorsal  vertebra  to 
the  end  of  the  sacrum.  Pressing  the  spine  occasioned 
a  spasmodic  movement  of  the  abdominal  muscles  and 
legs.  There  was  also  some  tenderness  at  the  fourth 
dorsal  vertebra,  and  pain  round  the  thorax  at  that  level. 
Sensation  in  the  legs  below  the  knees  was  greatly 
impaired.  Lying  in  bed  he  was  able  to  raise  the  right 
foot  slightly,  but  had  no  power  over  the  left.  Could 
just  manage  to  walk,  but  in  a  hobbling  manner.  He 
had  now  slightly  defective  power  over  the  sphincters. 

Urine  was  now  healthy.  Bowels  acted  very  irregu- 
larly.    Slept  badly,  but  did  not  dream  much. 

May  7th. — Patient  complains  to-day  of  cramps  in 
the  calves  of  his  legs,  which  he  has  not  had  before.     Can 


138  SPRAINS,   ETC., 

stand  on  one  leg,  but  for  a  few  minutes  only.  Bowels 
now  open.     Sleeps  fairly.     Appetite  tolerable. 

8th. — I  saw  him  and  ordered  one  grain  of  calomel 
with  half  a  grain  of  opium  every  six  hours,  dry  cupping 
to  the  spine,  to  be  followed  by  fomentations. 

9th. — He  has  been  greatly  relieved  by  the  dry  cup- 
ping. Bowels  open.  He  still  complains  of  great  ten- 
derness down  the  spine  on  pressure. 

15th. — Patient  continues  to  improve.  The  dry  cup- 
ping has  been  repeated.  Power  over  bladder,  and  sen- 
sation and  motion  in  the  legs  improves. 

17th. — Mouth  rather  sore.  Pills  to  be  taken  less  fre- 
quently. Blisters  to  be  applied  every  four  or  five  days 
down  the  spine. 

19th. — Much  better.  Sensation  and  motion  in  the 
legs  much  increased. 

27th. — Much  improved.  Sensation  in  the  legs  now 
normal.  Can  raise  them  both  from  the  bed  with  ease. 
Pain  in  the  back  nearly  gone.     Blistering  continued. 

30th. — Seems  almost  well.  Has  no  pain  whatever  in 
the  back,  and  touching  the  back  causes  no  spasm.  Has 
complete  power  over  the  bladder  and  the  rectum,  and 
can  walk  steadily,  and  stand  on  one  leg,  though  rather 
shakily  on  the  left.  He  only  complains  of  "fluttering 
sensations  in  the  inside." 

June  4th. — Continues  to  improve.  Gets  up  every 
day.  He  now  complains  of  the  light,  and  says  he  has 
a  headache,  and  a  tender  spot  in  the  loins.  To  keep  in 
bed. 

8th. — States  that  he  feels  all  right  again.  Headache 
gone,  and  also  the  tender  place.     To  get  up  again. 

17th. — Going  on  perfectly  well.  No  change  since 
last  report. 

Discharged  convalescent. 

March  23,  1868. — Patient  presented  himself  again  to- 
day. Since  leaving  the  Hospital  he  thinks  he  has  been 
getting  gradually  worse.  In  October  last  he  tried  to 
work,  but  was  so  much  worse  in  consequence  that  he 
had  to  go  into  St.  Bartholomew's  Hospital,  Chatham, 
where  he  remained  for  three  weeks.  Since  then  he  has 
been  getting  worse.     Complains   of    numbness  in   his 


OF  THE  SPINE.  1 39 

legs.  Sensation  perfect  in  both  legs  above  the  knee, 
defective  below  ,  firm  pressure  being  felt,  but  not  slight 
pressure.  Cannot  recognize  which  toe  is  pinched,  but 
thinks  that  when  the  great  toe  is  pinched  it  is  the  sec- 
ond one.  He  can  walk  about  half  a  mile  ;  then  his 
legs  tremble  and  he  can  walk  no  further. 

He  complains  of  constant  pain  in  the  head  (occi- 
pital region),  and  also  severe  occasional  pains  in  the 
groins,  the  pain  shooting  round  from  the  spine.  His 
urine  is  "  muddy  "  when  it  passes.  He  cannot  hold  it 
longer  than  two  hours.  Bowels  obstinately  confined. 
Sight  worse  of  late.  There  is  a  constant  dimness  before 
him,  and  when  he  reads  the  "  lines  run  into  one  another." 
His  hearing,  he  says,  is  gradually  getting  worse.  He 
describes  his  mind  as  in  a  state  of  ''constant  confusion." 
Memory  very  bad.  Sleeps  badly  at  night,  and  is  always 
dreaming: 

Pulse  96,  feeble.  Appetite  bad.  Tongue  coated  with 
a  white  fur. 

Ordered  to  take  small  doses  of  perchloride  of  mer- 
cury in  decoction  of  bark,  and  to  have  complete  rest. 

The  patient  continued  for  some  length  of  time  in  the 
Hospital,  but  deriving  no  material  benefit  was  dis- 
charged as  incurable. 

Case  40. — Strain  of  Back — Slowly  Progressive  Symp- 
toms— Gradual  Development  of  Cerebral  Symptoms. — 
D.  S.,  aged  54,  consulted  me  November  7,  1871.  He 
stated  that  three  years  before,  whilst  lifting  a  heavy 
box,  he  felt  that  he  had  strained  his  back  across  the  loins. 
He  was  seized  with  pain  in  this  region  and  a  sense  of 
weakness,  so  that  he  was  obliged  to  put  down  the  box 
at  once.  From  that  time  he  was  never  well ;  he  had 
become  weak,  unable  to  walk  as  he  did  before,  and  with- 
out being  able  to  define  any  precise  ailment,  stated  that 
he  had  not  felt  as  he  had  before  the  injury.  He  had 
become  thinner,  especially  in  the  legs,  and  always  felt 
a  weakness  and  a  pain  across  the  back.  About  four 
months  before  I  saw  him  he  first  began  to  complain  of 
head  symptoms. 

The  following  are  the  notes  taken  of  his  condition 
when  he  came  to  me  : — He  is  generally  weak.     He  com  • 


140  SPRAINS,   ETC., 

plains  of  pain  across  the  forehead,  sleeps  badly,  dreams 
much.  He  cannot  employ  his  mind  in  business  matters 
or  reading,  as  he  did  before  the  accident.  His  sight  has 
become  impaired,  and  he  has  a  benumbed  and  tingling 
feeling  in  the  legs.  The  head  is  hot ;  appetite  bad ; 
pulse  quick  and  feeble.  On  examining  the  spine,  con- 
siderable tenderness  on  pressure  was  found  over  the 
second  lumbar  vertebra,  with  pain  in  moving  the  body 
to  and  fro,  or  laterally. 

This  case  presents  an  instance  of  the  gradual  develop- 
ment of  cerebral  symptoms,  two  and  a  half  years  after 
an  indirect  injury  to  the  lumbar  spine.  Doubtless  owing 
to  the  extension  upwards  of  meningeal  irritation. 

Case  41. — Strain  of  Back  in  Wrestling — Sloivly  Pro- 
gressive  Symptoins — Spinal  Ancemia. — A.  B.,  aged  27, 
January  14,  1875,  In  May,  1870,  whilst  wrestling, 
strained  his  back  ;  did  not  suffer  much  at  the  time,  but 
on  following  night  had  much  twitching  in  the  legs  and 
arms.  Was  incapacitated  for  any  work  for  almost  a 
year ;  during  the  greater  part  of  this  time  was  unable 
to  walk  any  distance  round  the  garden,  or  half  a  mile 
at  most.  Scarcely  got  better,  but  to  a  certain  extent 
was  able  to  enter  upon  practice  as  a  medical  man,  but  not 
to  do  any  hard  work.  But  latterly  had  been  getting 
weaker  and  suffered  more  from  fatigue. 

He  now  complained  of  dulness  of  head,  at  times  con- 
fusion of  thought.  Pains  at  back  of  head  on  reading. 
Sleeps  heavily ;  dreams  much.  Sensation  affected. 
Feels  extreme  weakness  in  the  spine  and  legs;  not  a' 
sense  of  pain,  but  one  of  exhaustion  down  spine.  No 
pain  except  feeling  of  uneasiness  over  seventh  cervical 
vertebra.  Sexually  weak,  no  desire  or  power.  No  affec- 
tion of  sphincters  ;  cold  extremities  ;  looks  old  and 
worn.  Treatment  consisted  of  iron  and  quinine,  with 
the  continuous  current  to  the  spine  and  cold  douches 
to  the  back. 

Case  42. — Strain  of  Lumbar  Spine  in  a  man  pre- 
viously injured  by  fall  from  horse — Long  Persistence  of 
Symptoms. — T.  T.,  aged  38,  was  sent  to  me  by  Mr. 
Hooker,  of  Tunbridge,  on  May  7,  1869.  Two  and  a 
half  years  previously  he  had  been  thrown  from  his  horse 


OF  THE   SPINE.  141 

and  dragged  some  distance,  the  lower  part  of  the  back 
being  much  bruised  by  the  accident.  He  was  laid  up 
for  about  a  fortnight,  and  lost  power  of  the  right  leg. 
There  was  at  no  time  any  affection  of  the  sphincters. 
He  gradually  improved  up  to  a  certain  point,  where  he 
remained  stationary.  He  complained  of  weakness  in  the 
back,  of  numbness  and  darting  pains  in  the  right  leg, 
and  especially  of  cold.  He  also  experienced  a  clutch- 
ing sensation  in  his  back,  in  consequence  of  which  he 
had  not  been  able  to  ride  since  the  accident.  Last 
December,  whilst  lifting  a  heavy  weight,  he  felt  that  he 
had  strained  his  back,  suddenly  dropped  and  fell  to  the 
ground,  owing  to  his  legs  giving  way  under  him.  Both 
the  lower  extremities  became  numb,  and  he  suffered 
very  severe  pains,  ^'  fearful  pains,"  through  them.  He 
was  obliged  to  lie  on  the  floor  of  the  dining  room  for 
five  days,  not  being  able  to  move,  owing  to  the  exces- 
sive pain  which  was  induced  on  any  attempt  to  raise 
him.  He  gradually  but  very  slowly  improve  until  he 
was  able  to  get  about  on  crutches.  There  still  remains 
considerable  tenderness  in  the  lumbar  region,  from  the 
third  to  the  fifth  lumbar  vertebrae  inclusive,  and  pain 
in  the  right  gluteal  region. 

This  series  of  cases  will  illustrate  more  forcibly  than 
any  description  of  mine  the  ill  effects  and  manifold 
evils  that  may  result  to  the  spine,  the  membranes,  and 
the  cord  from  sprains,  wrenches,  or  twists  of  the  verte- 
bral column. 


LECTURE  Vn. 

ON  THE  MODE  OF  OCCURRENCE  OF  SHOCK,  AND  ON 
THE  PATHOLOGY  OF  CONCUSSION  OF  THE  SPINE. 

PART  I. 

ON  THE   MODE  OF   OCCURRENCE   OF   SHOCK. 

One  of  the  most  remarkable  circumstances  connected 
with  injuries  of  the  spine  is,  the  disproportion  that 
exists  between  the  apparently  trifling  accident  that  the 
patient  has  sustained,  and  the  real  and  serious  mischief 


142  MODE   OF   OCCURRENCE 

that  has  in  reality  occurred,  and  which  will  eventually 
lead  to  the  gravest  consequence.  Not  only  do  symp- 
toms of  concussion  of  the  spine  of  the  most  serious, 
progressive, and  persistent  character,  often  develop  them- 
selves after  what  are  apparently  slight  injuries,  but  fre- 
quently when  there  is  no  sign  whatever  of  external  in- 
jury. This  is  well  exemplified  in  Case  26,  the  patient 
having  been  partially  paralyzed  simply  by  slipping 
down  a  few  stairs  on  her  heels.  The  shake  or  jar  that 
is  inflicted  on  the  spine  when  a  person  jumping  from  a 
height  of  a  few  feet  comes  to  the  ground  suddenly  and 
heavily  on  his  heels  or  in  a  sitting  posture,  has  been 
well  known  to  surgeons  as  not  an  uncommon  cause  of 
spinal  weakness  and  debility.  It  is  the  same  in  railway 
accidents  ;  the  shock  to  which  the  patient  is  subjected 
being  followed  by  a  train  of  slowly-progressive  symp- 
toms indicative  of  concussion  and  subsequent  irritation 
and  inflammation  of  the  cord  and  its  membranes. 

It  is  not  only  true  that  the  spinal  cord  may  be  indi- 
rectly injured  in  this  way,  and  that  sudden  shocks  ap- 
plied to  the  body  are  liable  to  be  followed  by  the  train 
of  evil  consequences  that  we  are  now  discussing,  but  I 
may  even  go  farther,  and  say  that  these  symptoms  of 
spinal  concussion  seldom  occur  when  a  serious  injury 
has  been  inflicted  on  one  of  the  limbs,  unless  the  spine 
itself  has  at  the  same  time  been  severely  and  directly 
struck.  A  person  who  by  any  of  the  accidents  of  civil 
life  meets  with  an  injury  by  which  one  of  the  limbs  is 
fractured  or  dislocated,  necessarily  sustains  a  very  severe 
shock,  but  it  is  a  very  rare  thing  indeed  to  find  that  the 
spinal  cord  or  the  brain  has  been  injuriously  influenced 
by  this  shock  that  has  been  impressed  on  the  body.  It 
would  appear  as  if  the  violence  of  the  shock  expended 
itself  in  the  production  of  the  fracture  or  the  disloca- 
tion, and  that  a  jar  of  the  more  delicate  nervous  struc- 
tures is  thus  avoided.  I  may  give  a  familiar  illustration 
of  this  from  an  injury  to  a  watch  by  falling  on  the 
ground.  A  watchmaker  once  told  me  that  if  the  glass 
was  broken,  the  works  were  rarely  damaged ;  if  the 
glass  escapes  unbroken,  the  jar  of  the  fall  will  usually 
be  found  to  have  stopped  the  movement. 


OF   SHOCK.  143 

How  these  jars,  shakes,  shocks,  or  concussions  of 
the  spinal  cord  directly  influence  its  action  I  cannot 
say  with  certainty.  We  do  not  know  how  it  is  when  a 
magnet  is  struck  a  heavy  blow  with  a  hammer,  the 
magnetic  force  is  jarred,  shaken,  or  concussed  out  of 
the  horse-shoe.  But  we  know  that  it  is  so,  and  that 
the  iron  has  lost  its  magnetic  power.  So,  if  the  spine 
is  badly  jarred,  shaken,  or  concussed  by  a  blow  or  shock 
of  any  kind  communicated  to  the  body,  we  find  that 
the  nervous  force  is  to  a  certain  extent  shaken  out  of 
the  man,  and  that  he  has  in  some  way  lost  nerve-power. 
What  immediate  change,  if  any,  has  taken  place  in  the 
nervous  structure  to  occasion  this  effect,  we  no  more 
know  than  what  change  happens  to  a  magnet  when 
struck.  But  we  know  that  a  change  has  taken  place 
in  the  action  of  the  nervous  system  just  as  we  know 
that  a  change  has  taken  place  in  the  action  of  the  iron 
by  the  loss  of  it  magnetic  force. 

But  whatever  may  be  the  nature  of  the  primary 
change  that  is  produced  in  the  spinal  cord  by  a  concus- 
sion, the  secondary  effects  are  clearly  of  an  inflamma- 
tory character,  and  are  identical  with  those  phenomena 
that  have  been  described  by  Ollivier,  Abercrombie,  and 
others,  as  dependent  on  chronic  meningitis  of  the  cord, 
and  sub-acute  myelitis. 

One  of  the  most  remarkable  phenomena  attendant 
upon  this  class  of  cases  is,  that  at  the  time  of  the  occur- 
rence of  the  injury  the  sufferer  is  usually  quite  uncon- 
scious that  any  serious  accident  has  happened  to  him. 
He  feels  that  he  has  been  violently  jolted  and  shaken, 
he  is  perhaps  somewhat  giddy  and  confused,  but  he 
finds  no  bones  broken,  merely  some  superficial  bruises 
or  cuts  on  the  head  and  legs,  perhaps  no  evidence  what- 
ever of  external  injury.  He  congratulates  himself  upon 
his  escape  from  the  imminent  peril  to  which  he  has  been 
exposed.  He  becomes  unusually  calm  and  self-pos- 
sessed; assists  his  less-fortunate  fellow-sufferers,  occupies 
himself  perhaps  actively  in  this  way  for  several  hours, 
and  then  proceeds  on  his  journey. 

When  he  reaches  his  home,  the  effects  of  the  injury 
that  he  has  sustained  begin  to  manifest  themselves.     A 


144  MODE   OF   OCCURRENCE 

revulsion  of  feeling  takes  place.  He  bursts  into  tears, 
becomes  unusually  talkative,  and  is  excited.  He  can- 
not sleep,  or,  if  he  does,  he  wakes  up  suddenly  with  a 
vague  sense  of  alarm.  The  next  day  he  complains  of 
feeling  shaken  or  bruised  all  over,  as  if  he  had  been 
beaten,  or  had  violently  strained  himself  by  exertion  of 
an  unusual  kind.  This  stiff  and  strained  feeling  chiefly 
affects  the  muscles  of  the  neck  and  loins,  sometimes 
extending  to  those  of  the  shoulders  and  thighs.  After 
a  time,  which  varies  much  in  different  cases,  from  a 
day  or  two  to  a  week  or  more,  he  finds  that  he  is  unfit 
for  exertion  and  unable  to  attend  to  business.  He  now 
lays  up,  and  perhaps  for  the  first  time  seeks  surgical 
assistance. 

This  is  a  general  sketch  of  the  early  history  of  most 
of  these  cases  of  "  Concussion  of  the  Spine"  from  rail- 
way accidents.  The  details  necessarily  vary  much  in 
different  cases. 

There  is  great  variation  in  the  period  at  which  the 
more  serious,  persistent,  and  positive  symptoms  of 
spinal  lesion  begin  to  develop  themselves.  In  some 
cases  they  do  so  immediately  after  the  occurrence  of  the 
injury,  in  others  not  until  several  weeks,  I  might  per- 
haps even  say  months,  had  elapsed.  But  during  the 
whole  of  this  interval,  Avhether  it  be  of  short  or  of  long 
duration,  it  will  be  observed  that  the  sufferer's  condi- 
tion, mentally  and  bodily,  has  undergone  a  change. 
This  is  a  point  on  w^iich  I  would  particularly  insist.  He 
never  completely  gets  over  the  affects  of  the  accident. 
There  may  be  improvement;  there  is  not  recovery. 
There  is  a  continuous  chain  of  broken  or  ill  health, 
between  the  time  of  occurrence  of  the  accident  and  the 
development  of  the  more  serious  symptoms.  It  is  this 
that  enables  the  surgeon  to  connect  the  two  in  the  rela- 
tion of  cause  and  effect.  This  is  not  peculiar  to  rail- 
way injuries,  but  it  occurs  in  all  cases  of  progressive 
paralysis  after  spinal  concussion,  and  may  be  noted  in 
the  histories  of  many  that  have  been  given  in  these 
lectures.  The  friends  remark,  and  the  patient  feels, 
that  "he  is  not  the  man  he  was."  He  has  lost  bodily 
energy,  mental  capacity,  business  aptitude.     He  looks 


OF  SHOCK.  145 

ill  and  worn;  often  becomes  irritable  and  easily  fatigued. 
He  still  believes  that  he  has  sustained  no  serious  or 
permanent  hurt,  tries  to  return  to  his  business,  finds 
that  he  cannot  apply  himself  to  it,  takes  rest,  seeks 
change  of  air  and  scene,  undergoes  medical  trea'tment 
of  various  kinds,  but  finds  all  of  no  avail.  His  symp- 
toms become  progressively  more  and  more  confirmed, 
and  at  last  he  resigns  himself  to  the  conviction  that  he 
has  sustained  a  more  serious  bodily  injury  than  he  had 
at  first  believed,  and  one  that  has,  in  some  way  or 
other,  broken  down  his  nervous  power,  and  has  wrought 
the  change  of  converting  a  man  of  mental  energy  and 
of  active  business  habits  into  a  valetudinarian,  a  hypo- 
chondriac or  a  hysterical  paralytic,  utterly  unable  to 
attend  to  the  ordinary  duties  of  life. 

The  condition  in  which  a  patient  will  be  at  this  or  a 
later  period  of  his  sufferings,  will  be  found  detailed  in 
several  cases  that  have  been  related. 

It  may,  however,  throw  additional  light  on  this  sub- 
ject, if  we  analyze  the  symptoms,  and  arrange  them  in 
the  order  in  which  they  will  present  themselves  on 
making  a  surgical  examination  of  such  a  patient;  bear- 
ing this  important  fact  in  mind,  however,  that  although 
all  and  everyone  of  these  symptoms  may  present  them- 
selves in  any  given  case,  yet  that  they  are  by  no  means 
all  necessarily  present  in  any  one  case.  Indeed  this 
usually  happens,  and  we  generally  find  that  whilst  some 
symptoms  assume  great  prominence,  others  are  propor- 
tionally dwarfed,  or,  indeed,  completely  absent.  In 
these  as  in  so  many  other  cases,  whether  surgical  or 
medical,  it  is  well  not  to  lay  too  much  stress  on  the 
presence  or  absence  of  any  one  particular  symptom,  but 
we  should  take  all  the  symptoms  that  present  them- 
selves in  one  group. 

The  countenance  is  unusually  pallid,  lined,  and  has  a 
peculiarly  care-worn,  anxious  expression,  the  patient 
generally  looking  much  older  than  he  really  is  or  than 
he  did  before  the  accident.  Occasionally  there  is 
flushing  of  the  cheek  and  ear  or  of  the  forehead,  accom- 
panied by  a  sensation  of  great  heat. 

The  memory  is  defective.  The  defect  of  memory 
10 


146  MODE   OF   OCCURRENCE 

shows  itself  in  various  ways;  thus,  Case  2  said  that  he 
could  not  recollect  a  message  unless  he  wrote  it  down; 
Case  10  forgot  some  common  words  and  mis-spelt 
others;  Case  18  lost  command  over  figures,  he  could  not 
add  up  a  few  figures,  and  had  also  lost,  in  a  great 
degree,  the  faculty  of  judging  of  weight,  and  of  distance 
in  a  lateral  direction;  he  forgot  dates,  the  ages  of  his 
children,  &c. 

The  thoughts  are  confused.  The  patient  will  some- 
times, as  in  Case  28,  break  oE  in  the  middle  of  a  sen- 
tence, unable  to  finish  it;  he  cannot  concentrate  his 
ideas  so  as  to  carry  on  a  connected  line  of  argument; 
he  attempts  to  read,  but  is  obliged  to  lay  aside  the 
book  or  paper  after  a  few  minutes,  not  from  weakness 
of  sight,  but  from  confusion  of  thought  and  inability  to 
maintain  a  continuous  mental  strain. 

All  business  aptitude  is  lost,  partly  as  a  consequence 
of  impairment  of  memory,  partly  of  confusion  of  thought 
and  inability  to  concentrate  ideas  for  a  sufficient  length 
of  time.  The  will  becomes  enfeebled;  the  power  of 
decision  is  lost;  the  mind  becomes  vacillating,  and 
impotent  of  will. 

The  temper  is  often  changed  for  the  worse,  the 
patient  becoming  fretful,  irritable,  and  in  some  way — • 
difificult  perhaps  to  define,  but  easily  appreciated  by 
those  around  him — altered  in  character. 

The  sleep  is  disturbed,  restless  and  broken.  He 
wakes  up  in  sudden  alarm ;  dreams  much ;  the  dreams 
are  distressing  and  horrible. 

The  head  is  usually  of  its  natural  temperature,  but 
sometimes  hot.  The  patient  complains  of  various 
uneasy  sensations  in  it ;  of  pain,  tension,  weight,  or 
throbbing  ;  of  giddiness  ;  or  of  a  confused  or  constrained 
feeling.  Frequently  loud  and  incessant  noises,  described 
as  roaring,  rushing,  ringing,  singing,  sawing,  rumbling, 
or  thundering  are  experienced.  These  noises  vaiy  in 
intensity  at  different  periods  of  the  day,  but  if  once 
they  occur,  are  never  entirely  absent,  and  are  a  source 
of  great  distress  and  disquietude  to  the  patient. 

The  organs  of  special  sense  usually  become  more  or 
less  seriously  affected,     They  may  be  over  sensitive  and 


OF  SHOCK.  T47 

irritable,  blunted  in  their  perceptions,  or  perverted  in 
their  sensations.  In  many  cases  we  find  a  combination 
of  all  these  conditions  in  the  same  organ. 

Vision. — The  impairment  of  vision  is  so  important  in 
concussion  of  the  spine  that  I  shall  devote  a  special 
lecture  to  it,  to  which  I  must  refer  you  for  details.  It 
suffices  now  to  give  a  brief  sketch  of  the  troubles  con- 
nected with  it  in  these  cases  of  railway  shock.  In  some 
cases,  though  rarely,  there  is  double  vision  and  perhaps 
slight  strabismus.  In  others  an  alteration  in  the  focal 
length,  so  that  the  patient  has  to  begin  the  use  of 
glasses,  or  to  change  those  he  has  previously  worn.  The 
patient  suffers  from  asthenopia,  he  cannot  read  for  more 
than  a  few  minutes,  the  letters  running  into  one  another. 
More  commonly,  muscse  volitantes  and  spectra,  rings, 
stars,  flashes,  sparks — white,  colored,  or  flame-like — are 
complained  of.  The  eyes  often  become  over  sensitive 
to  light,  so  that  the  patient  habitually  sits  in  a  shaded 
or  darkened  room,  turns  his  back  to  the  window,  and 
cannot  bear  unshaded  gas  or  lamp-light.  This  intoler- 
ance of  light  may  amount  to  positive  photophobia.  It 
gives  rise  to  a  habitually  contracted  state  of  the  brows, 
so  as  to  exclude  light  as  much  as  possible  from  the  eyes. 
One  or  both  eyes  may  be  thus  affected.  Sometimes 
one  eye  only  is  intolerant  of  light.  This  intolerance  of 
light  may  be  associated  with  dimness  and  imperfection 
of  sight.  Perhaps  vision  is  normal  in  one  eye,  but 
impaired  seriously  in  the  other.  The  circulation  at  the 
back  of  the  eye  is  visible  to  some  patients,  when  they 
look  up  at  a  clear  sky  or  on  a  white  paper.  Irregularity 
of  the  pupils  is  sometimes  noticed,  one  being  dilated, 
the  other  normal  or  contracted. 

The  hearing  may  be  variously  affected.  Not  only 
does  the  patient  commonly  complain  of  the  noises  in 
the  head  and  ears  that  have  already  been  described,  but 
the  ears,  like  the  eyes,  may  be  over  sensative  or  too 
dull.  One  ear  is  frequently  over  sensitive  whilst  the 
other  is  less  acute  than  it  was  before  the  accident.  The 
relative  sensibility  of  the  ears  may  readily  be  measured 
by  the  distance  at  which  the  tick  of  a  watch  may  be 
heard.     Loud  and  sudden  noises  are  particularly  dis- 


148  MODE  OF  Occurrence 

tressing  to  these  patients.  The  fall  of  a  tray,  the  rattle 
of  a  carriage,  the  noise  of  children  at  play,  are  all  sources 
of  pain  and  of  irritation.  Deafness  occasionally  comes 
on  in  the  course  of  the  case  ;  but  it  is  not  an  early  symp- 
tom. If  the  deafness  is  owing  to  injury  inflicted  on  the 
auditory  nerve  or  on  the  brain,  the  patient  will  not  be 
able  to  hear  on  the  affected  side  the  vibrations  of  a 
tuning  fork  when  the  instrument  is  applied  to  the  fore- 
head. But  if  the  defect  be  dependent  on  obstructive 
disease  or  of  injury  of  the  external  or  middle  ear,  the 
nervous  apparatus  being  perfect,  the  vibrations  trans- 
mitted throughout  the  bones  of  the  skull  will  not  only 
be  audible  in  the  affected  ear,  but  being  retained  there, 
and  prevented  passing  outwards,  are  actually  heard  more 
loudly  in  it  than  in  the  sound  one. 

Taste  and  smell  are  much  less  frequently  affected 
than  sight  or  hearing ;  but  they  may  be  perverted  or 
lost.  The  sense  of  smell  is  more  frequently  affected 
than  that  of  taste.  It  may  be  perverted  so  that  the 
patient  thinks  that  he  is  always  smelling  a  fetid  odor. 
It  is  always  disagreeably,  never  pleasantly  perverted. 
When  once  lost,  it  is  never  recovered.  I  have  never 
known  the  sense  of  taste  to  be  lost ;  that  is  to  say,  I 
have  never  known  a  patient  who  could  not  distinguish 
between  salt  and  sugar ;  but  owing  to  the  frequent 
impairment  or  loss  of  the  sense  of  smell,  the  perception 
or  taste  of  flavors  is  often  lost,  in  the  perception  of 
which  the  sense  of  smell  plays  as  important  a  part  as 
that  of  taste. 

The  sense  of  touch  is  impaired.  The  patient  cannot 
pick  up  a  pin,  cannot  button  his  dress,  cannot  feel  the 
difference  between  different  textures,  as  cloth  and  vel- 
vet. He  loses  the  sense  of  weight,  cannot  tell  whether 
a  sovereign  or  a  shilling  is  balanced  on  his  finger. 

Speech  is  rarely  affected.  Case  29  stammered  some- 
what before  the  accident,  but  after  it  his  speech  became 
a  most  painful  and  indescribably  confused  stutter  that 
it  was  almost  impossible  to  comprehend.  The  same 
phenomenon  was  observed  in  the  Count  de  Lordat's 
case.     But  it  is  certainly  rare. 

The  attitude  of  these  patients  is  usually  peculiar. 


OF  SHOCK.  149 

It  Is  stiff  and  unbending.  They  hold  themselves  very- 
erect,  usually  walk  straight  forwards,  as  if  afraid  or 
unable  to  turn  to  either  side.  The  movements  of  the 
head  or  trunk,  or  both,  do  not  possess  their  natural  free- 
dom. There  may  be  pain  or  difificulty  in  moving  the 
head  in  the  antero-posterior  direction,  or  in  rotating  it, 
or  all  movements  may  be  attended  by  so  much  pain  and 
difficulty  that  the  patient  is  afraid  to  attempt  them, 
and  hence  he  keeps  the  head  in  its  attitude  of  immo- 
bility. 

The  movements  of  the  trunk  are  often  equally 
restrained,  especially  in  the  lumbar  region.  Bending 
forwards,  backwards,  or  sideways,  is  painful,  difficult, 
and  may  be  impossible  ;  bending  backwards  is  usually 
liiost  complained  of. 

If  the  patient  is  asked  to  stoop  and  pick  up  anything 
off  the  ground,  he  will  not  be  able  to  do  so  in  the  usual 
way,  but  goes  down  on  the  knee  and  so  reaches  the 
ground. 

If  he  is  laid  horizontally  and  told  to  raise  himself 
up  without  the  use  of  his  hands,  he  will  be  unable  to 
do  so. 

The  state  of  the  spine  will  be  found  to  be  the  real 
cause  of  all  these  symptoms. 

On  examining  it  by  pressure,  by  percussion,  or  by 
the  application  of  the  hot  sponge,  it  will  be  found  that 
it  is  painful,  and  that  its  sensibility  is  exalted  at  one, 
two,  or  three  points.  These  are  usually  in  the  upper 
or  lower  cervical,  the  middle  dorsal,  and  the  lumbar 
regions.  The  vertebrae  that  are  affected  very  neces- 
sarily in  different  cases,  but  the  exalted  sensibility 
always  includes  two,  and  usually  three,  at  each  of  these 
points.  It  is  on  account  of  the  pain  occasioned  by  any 
movement  of  the  trunk  by  way  of  flexion  or  rotation, 
that  the  spine  loses  its  natural  suppleness,  and  that  the 
vertebral  column  moves  as  a  whole,  as  if  cut  out  of  one 
solid  piece,  instead  of  with  the  flexibility  that  its  vari- 
ous component  parts  naturally  gives  to  all  its  move- 
ments. 

The  movements  of  the  head  upon  the  upper  cervical 
vertebm;   arc   variously  affected.     In   some   cases    the 


I50  MODE   OF  OCCURRENCE 

head  moves  freely  in  all  directions,  without  pain  or  stifF- 
ness,  these  conditions  existing  in  the  lower  and  middle, 
rather  than  in  the  upper  cervical  vertebrae.  In  other 
cases,  again,  the  greatest  agony  is  induced  if  the  sur- 
geon takes  the  head  between  his  hands  and  bends  it 
forwards  or  rotates  it,  the  articulations  between  the 
occipital  bone,  the  atlas,  and  the  axis  being  evidently 
in  a  state  of  inflammatory  irritation.  This  happened  in 
a  very  marked  manner  in  Cases  i8  and  19 ;  and  in  both 
these  it  is  interesting  to  observe  that  different  evidences 
of  cerebral  irritation  had  been  superadded  to  those  of 
the  more  ordinary  spinal  mischief. 

The  pain  is  usually  confined  to  the  vertebral  column, 
and  does  not  extend  beyond  the  transverse  processes. 
But  in  some  instances,  as  in  Case  2,  the  pain  extended 
widely  over  the  back  on  both  sides,  more  on  the  left 
than  on  the  right,  and  seemed  to  correspond  with  the 
distribution  of  the  posterior  branches  of  the  dorsal 
nerves.  In  these  cases,  owing  to  the  musculo-cutaneous 
distribution  of  these  nerves,  the  pain  is  superficial  and 
cutaneous  as  well  as  deeply-seated  in  the  spine. 

The  muscles  of  the  back  are  usually  unaffected,  but 
in  some  cases  where  the  muscular  branches  of  the  dorsal 
nerves  are  affected,  as  in  Case  19,  they  may  be  found  to 
be  very  irritable  and  spasmodically  contracted,  so  that 
their  outlines  are  very  distinct  and  marked. 

The  gait  of  the  patient  is  remarkable  and  character- 
istic. He  walks  more  or  less  unsteadily,  very  like  a 
person  who  is  partially  inebriated,  or  like  one  suffering 
from  locomotor  ataxy ;  generally  he  uses  a  stick,  or  if 
deprived  of  that,  he  is  apt  to  lay  his  hand  on  any  article 
of  furniture  that  is  near  him,  with  the  view  of  steadying 
himself. 

He  keeps  his  feet  somewhat  apart,  so  as  to  increase 
the  basis  of  support,  and  consequently  walks  in  a  strad- 
dling manner. 

One  leg  is  often  weaker  than  the  other,  the  left  more 
frequently  than  the  right.  Hence  he  totters  somewhat, 
raises  the  weak  foot  but  slightly  off  the  ground,  so  that 
the  heel  is  apt  to  touch.  He  often  drags  the  toe,  or, 
walking  flat-footed,  drags  the  heel.     This  peculiar  strad- 


OF   SHOCK.  151 

dling,  tottering,  unsteady  gait,  with  the  rigid  spine,  the 
erect  head,  while  the  patient  looks  straight  forward, 
gives  him  the  aspect  of  a  man  who  walks  blindfolded. 

The  patient  cannot  generally  stand  equally  well  on 
either  foot.  One  leg,  usually  the  left,  immediately  gives 
way  under  him  if  he  attempts  to  stand  on  it- 
He  often  cannot  raise  himself  on  his  toes,  or  stand  on 
them,  without  immediately  tottering  forwards. 

His  power  of  walking  is  always  very  limited  ;  it  seldom 
exceeds  half  a  mile  or  a  mile  at  the  utmost. 

He  cannot  ride,  even  if  much  in. the  habit  of  doing 
so  before  the  accident.     He  loses  both  grip  and  balance. 

There  is  usually  considerable  difficulty  in  going  up 
and  down  stairs — more  difficulty  in  going  down  than 
up.  The  patient  is  obliged  to  support  himself  by  hold- 
ing on  to  the  balusters,  and  often  brings  both  feet 
together  on  the  same  step. 

A  sensation  as  of  a  cord  tied  round  the  waist,  with 
occassional  spasm  of  the  diaphragm,  giving  rise  to  a 
catch  in  the  breathing,  or  hiccup,  is  sometimes  met  with, 
and  is  very  distressing  when  it  does  occur. 

The  motor  power  and  sensation  will  be  found  to  be 
variously  modified,  and  will  generally  be  so  to  very 
different  degrees  in  the  different  limbs.  I  have  fully 
described  the  various  modifications  of  motion  and  sen- 
sation in  cases  of  direct  spinal  injury  in  Lecture  H.,  and 
would  refer  to  this  account,  which  will  be  found  closely 
to  resemble  the  phenomena  that  result  form  nervous 
shock  in  railv/ay  collisions.  Sometimes  one  limb  only 
is  affected,  at  others  the  arm  and  leg  on  one  side,  or 
both  legs  only,  or  the  arm  and  both  legs,  or  all  four 
limbs,  are  the  seat  of  uneasy  sensations.  There  is  the 
greatest  possible  variety  in  these  respects,  dependent  of 
course  entirely  upon  the  degree  and  extent  of  the 
lesion  that  has  been  inflicted  upon  or  induced  in  the 
spinal  cord. 

Sensation  only  may  be  affected,  or  it  may  be  normal, 
and  motion  may  be  impaired  ;  or  both  may  be  affected 
to  an  equal,  or  one  to  a  greater  and  the  other  to  a  less, 
degree.  And  these  conditions  may  happen  in  one  or 
more   limbs.     Thus   sensation  and    motion     may     be 


152  MODE   OF  OCCURRENCE 

seriously  impaired  in  one  limb,  or  sensation  in  one  and 
motion  in  another.  The  paralysis  is  seldom  complete. 
It  may  become  so  in  the  more  advanced  stages  after  a 
lapse  of  several  years,  but  for  the  first  year  or  two  it  is 
(except  in  cases  of  direct  and  severe  violence)  almost 
always  partial.  It  is  sometimes  incompletely  recovered 
from,  especially  so  far  as  sensation  is  concerned. 

The  loss  of  motor  power  is  usually  greater  and,  as  a 
rule,  is  always  more  apparent  than  that  of  sensation. 
In  many  cases  sensation  undoubtedly  continues  perfect, 
whilst  the  motor  power  is  seriously  impaired.  In  other 
cases,  again,  motion  appears  to  be  more  seriously 
affected  than  sensation,  simply  because  it  is  so  much 
easier  to  test  and  to  appreciate  the  full  extent  of  the 
loss  of  motor  than  of  sensory  power. 

The  loss  of  motor  power  is  especially  marked  in  the 
legs,  and  more  in  the  extensor  than  in  the  flexor 
muscles.  The  extensor  of  the  great  toe  is  especially 
apt  to  suffer.  The  hand  and  arm  are  less  frequently 
the  seats  of  Joss  of  motor  power  than  the  leg  and  foot ; 
but  the  muscle  of  the  ball  of  the  thumb,  or  the  flexors 
of  the  fingers,  may  be  so  affected. 

It  will  be  found  that  these  symptoms  of  paraplegia 
are  much  more  marked  when  the  patient  stands  up 
than  when  he  lies  down.  In  this  respect,  indeed,  the 
form  of  partial  paralysis  that  we  are  now  considering 
resembles  those  forms  of  the  disease  that  arise  from 
other  causes  than  injury.  A  patient  who  can  scarcely 
stand,  and  who  walks  with  a  feeble,  tottering,  jerking 
gait,  will,  when  he  lies  down,  readily  move  his  limbs  in 
any  direction,  and  exercise  a  considerable  amount  of 
power  either  in  flexion  or  extension.  Whether  this  is 
due,  as  Matthew  Baillie  supposed,  to  the  increased 
pressure  of  the  cord  by  the  spinal  fluid,  or  to  the  greater 
venous  congestion  of  the  lower  portion  whilst  the 
patient  is  standing  than  when  he  lying  down,  may  be 
matter  of  speculation,  but  the  fact  is  certain  that  in  all 
cases  of  incipient  and  partial  paraplegia,  the  spmptoms 
are  most  marked  when  the  patient  stands,  and  subside 
to  a  great  extent  when  he  lies  down. 

The  loss  of  motor  power  in  the  foot  and  leg  is  best 


OF  SHOCK.  153 

tested  by  the  application  of  the  galvanic  current,  so  as 
to  compare  the  irritability  of  the  same  muscles  of  the 
opposite  limbs.  The  value  of  the  electric  test  is,  that 
it  is  not  under  the  influence  of  the  patient's  will,  and 
that  a  very  true  estimate  can  thus  be  made  of  the  loss 
of  contractility  in  any  given  set  of  muscles. 

The  loss  of  motor  power  in  the  hand  is  best  tested 
by  the  force  of  the  patient's  grasp.  This  may  be 
roughly  estimated  by  telling  him  to  squeeze  the  sur- 
geon's fingers,  first  with  one  hand  and  then  the  other, 
or  more  accurately  by  means  of  the  dynamometer, 
which  shows  on  an  index  the  precise  amount  of  pressure 
that  a  person  exercises  in  grasping. 

It  is  in  consequence  of  the  diminution  of  motor 
power  in  the  legs  that  those  peculiarities  of  gait  which 
have  just  been  described  are  met  with,  and  they  are 
most  marked  when  the  amount  of  loss  is  unequal  in 
the  two  limbs,  as  the  paraplegia  is  partial.  The  sphinc- 
ters are  very  rarely  affected  in  the  cases  now  under 
consideration.  Sometimes  there  is  increased  frequency 
of  micturition,  but  I  have  rarely  met  with  retention  of 
urine  or  with  cases  requiring  the  continued  use  of  the 
catheter ;  nor  have  I  observed  in  any  case  that  the  con- 
tractility of  the  sphincter  ani  had  been  so  far  impaired 
as  to  lead  to  involuntary  escape  of  flatus  or  faeces. 

Modification  or  diminution  of  sensation  in  the  limbs 
is  one  of  the  most  marked  phenomena  in  these  cases. 

In  many  instances  the  sensibility  is  a  good  deal 
augmented,  especially  in  the  earlier  stages.  The  patient 
complains  of  shooting  pains  down  the  limbs,  like  stabs, 
darts,  or  electrical  shocks.  The  surface  of  the  skin  is 
sometimes  over-sensitive  in  places  in  the  back  (as  in 
Case  19),  or  in  various  parts  of  the  limbs,  hot,  burning- 
sensations  are  experienced  in  it.  After  a  time  these 
sensations  give  place  to  various  others,  which  are  very 
differently  described  by  patients.  Tinglings,  a  feeling 
of  "  pins  and  needles,"  a  heavy  sensation,  as  if  the  limb 
was  asleep,  creeping  sensations  down  the  back  and  along 
the  nerves,and  formications,are  all  commonly  complained 
of.  These  sensations  are  often  confined  to  one  nerve 
in  a  limb,  as  the  ulnar  for  instance,  or  the  musculo-spiral. 


154  MODE   OF   OCCURRENCE 

The  existence  of  numbness  does  not  necessarily  imply 
loss  of  the  sense  of  touch.  The  fingers  may  feel  ^'  numb  " 
and  yet  be  well  able  to  detect  the  difference  between 
hard  and  smooth,  soft  and  rough,  moist  and  dry  things. 

Numbness,  more  or  less  complete,  may  exist  inde- 
pendently of,  or  be  associated  with,  all  these  various 
modifications  of  sensation,  with  pain,  tingling,  or  creep- 
ing sensations.  Its  extent  will  vary  greatly  ;  it  may  be 
confined  to  a  part  of  a  limb,  may  influence  the  whole  of 
it,  or  may  extend  to  two,  three,  or  even  to  the  four 
limbs ;  its  degree  and  extent  are  best  tested  by  Brown- 
S^quard's  aesthesiometer. 

Coldness  of  one  of  the  extremities  dependent  upon 
actual  loss  of  nervous  power,  and  defective  nutrition, 
is  often  perceptible  to  the  touch,  and  may  be  accurately 
determined  by  the  clinical  thermometer ;  but  in  many 
cases  it  is  found  that  the  sensation  of  coldness  is  far 
greater  to  the  patient  than  it  is  to  the  surgeon's  hand, 
and  not  unfrequently  no  appreciable  difference  in  the 
temperature  of  two  limbs  can  be  determined  by  the 
most  delicate  clinical  thermometer,  although  the  patient 
experiences  a  very  distinct  and  distressing  sense  of  cold- 
ness in  one  of  the  limbs. 

The  condition  of  the  limbs  as  to  size,  and  the  state  of 
their  muscles,  will  vary  greatly. 

In  some  cases  of  complete  paraplegia,  which  has  lasted 
for  years,  as  in  Case  4,  it  has  been  remarked  that  no 
diminution  whatever  had  taken  place  in  the  size  of  the 
limbs.  This  was  also  the  case  in  Case  2,  where  the 
paralysis  was  partial.  It  is  evident,  therefore,  that  loss 
of  size  in  a  limb  which  is  more  or  less  completely  para- 
lyzed is  not  the  simple  consequence  of  the  disuse  of  the 
muscles,  or  it  would  always  occur.  But  it  must  arise 
from  some  modification  of  innervation,  influencing  the 
nutrition  of  the  limb,  independently  of  the  loss  of  mus- 
cular activity. 

In  most  cases,  however,  where  the  paralytic  con- 
dition has  been  of  some  duration,  the  size  of  the  limb 
dwindles  ;  and  on  accurate  measurement  it  will  be  found 
to  be  somewhat  smaller  in  circumference  than  its  fellow 
on  the  opposite  side. 


OF  SHOCK.  155 

The  state  of  the  muscles  as  to  firmness  will  also  vary. 
Most  commonly  when  a  limb  dwindles  the  muscles 
become  soft,  and  the  inter-muscular  spaces  more  dis- 
tinct. Occasionally  in  advanced  cases  a  certain  degree 
of  contraction  and  of  rigidity  in  particular  muscles  sets 
in.  Thus  the  flexors  of  the  little  and  ring  fingers,  the 
extensors  of  the  great  toe,  the  deltoid  or  the  muscles 
of  the  calf,  may  all  become  the  seats  of  more  or  less 
rigidity  and  contraction. 

The  electric  irritability  of  the  muscles  of  the  partially 
paralyzed  limb  is  much  lessened,  sometimes  destroyed, 
in  certain  groups  of  muscles,  whilst  it  continues  more 
or  less  perfect  in  others. 

The  body  itself  generally  loses  weight ;  and  a  loss  of 
weight,  when  the  patient  is  deprived  of  all  exercise,  and 
is  rendered  inactive  by  a  semi-paralyzed  state,  and  takes 
a  fair  quantity  of  good  food,  which  he  digests  sufficiently 
well,  is  undoubtedly  a  very  important  and  a  very  serious 
sign,  and  may  usually  be  taken  to  be  indicative  of  pro- 
gressive disease  in  the  nervous  system. 

When  the  progress  of  the  disease  has  been  arrested, 
though  the  patient  may  be  permanently  paralyzed,  we 
often  see  a  considerable  increase  of  size  and  weight  take 
place.  As  nerve  action  becomes  enfeebled,  the  grosser 
corporeal  elements  attain  preponderance — adipose  mat- 
ter is  deposited.  This  is  a  phenomenon  of  such  common 
occurrence  in  ordinary  cases  of  paralysis  from  disease 
of  the  brain,  that  I  need  do  no  more  than  mention  that 
it  is  also  of  not  unfrequent  occurrence  in  those  forms 
that  proceed  from  injury,  whether  of  the  cord  or  brain. 

The  condition  of  the  Genito-Urinary  organs  is  sel- 
dom much  deranged  in  the  cases  under  consideration, 
as  there  is  usually  no  paralysis  of  the  sphincters. 
Neither  retention  of  urine  nor  incontinence  of  flatus 
and  faeces  occurs.  Sometimes,  however,  irritability  of 
the  bladder  is  a  prominent  symptom.  The  urine  gene- 
rally retains  its  acidity,  sometimes  markedly,  at  others 
but  very  slightly  so.  As  there  is  no  retention,  it  does 
not  become  alkaline,  ammoniacal,  or  otherwise  offen- 
sive. 

Priapism  does  not  occur  in  these  cases  as  in  menin- 


156  MODE   OF   OCCURRENCE 

geal  irritation,  or  in  fractures  with  laceration  of,  or 
pressure  on,  the  cord. 

The  sexual  desire  and  power  are  usually  greatly 
impaired,  and  often  entirely  and  permanently  lost.  Not 
invariably  so,  however.  The  Avif e  of  Case  18  miscarried 
twice  during  the  twelvemonth  succeeding  her  husband's 
accident. 

The  pulse  varies  in  frequency  at  different  periods. 
In  the  early  stages  it  is  usually  slow.  In  the  more 
advanced  it  is  quick,  near  to  or  above  100.  In  one  case 
I  found  it  unequal  at  the  two  wrists.  It  is  always 
feeble,  and  sometimes  irregular  or  intermitting.  The 
skin  is  usually  cold  and  clammy. 

The  order  of  the  progressive  development  of  the 
various  symptoms  that  have  just  been  detailed  is  a 
matter  of  great  interest  in  these  cases.  As  a  rule, 
each  separate  symptom  comes  on  very  gradually  and 
insidiously.  It  usually  extends  over  a  lengthened 
period. 

In  the  early  stages,  the  chief  complaint  is  a  sensation 
of  lassitude,  weariness,  and  inability  for  mental  and 
physical  exertion.  Then  come  the  pains,  tinglings,  and 
numbness  of  the  limbs;  next  the  fixed  pain  and  rigid- 
ity of  the  spine;  then  the  mental  confusion,  and  signs 
of  cerebral  disturbance,  and  the  affection  of  the  organs 
of  the  sense;  the  loss  of  motor  power,  and  the  peculiar- 
ity of  gait. 

The  period  of  supervention  of  these  symptoms  after 
the  occurrence  of  the  injury  will  greatly  vary.  In 
cases  of  severe  and  direct  concussion  of  the  spine,  the 
symptoms  are  usually  immediate  and  distinctly  marked. 
In  the  cases  of  general  nervous  shock,  and  of  slight  and 
indirect  concussion  of  the  cord,  no  immediate  effects 
are  produced,  or  if  they  are,  they  are  transitory,  and 
commonly  after  the  first  and  immediate  effects  of  the 
accident  have  passed  off  there  is  a  period  of  compara- 
tive ease,  and  of  remission  of  the  symptoms,  but  not  of 
recovery,  during  which  the  patient  imagines  that  he 
will  speedily  regain  his  health  and  strength.  This 
period  may  last  for  many  weeks,  possibly  for  two  or 
three  months.     At  this  time  there  will  be  considerable 


OF   SHOCK.  157 

fluctuation  in  the  patient's  condition.  So  long  as  he  is 
at  rest,  he  will  feel  tolerably  well;  but  any  attempt  at 
ordinary  exertion  of  body  or  mind  brings  back  all  the 
feelings  and  indications  of  nervous  prostration  and  irri- 
tation so  characteristic  of  these  injuries;  and  to  these 
will  gradually  be  superadded  those  more  serious  symp- 
toms that  have  already  been  fully  detailed,  which  evi- 
dently proceed  from  a  chronic  disease  of  the  cord  and 
its  membranes.  After  a  lapse  of  several  months — from 
three  to  six — the  patient  will  find  that  he  is  slowly  but 
steadily  becoming  worse,  and  he  then,  perhaps  for  the 
first  time,  becomes  aware  of  the  serious  and  deep-seated 
injury  that  his  nervous  system  has  sustained. 

Although  there  is  often  this  long  interval  between 
the  time  of  the  occurrence  of  the  accident  and  the 
supervention  of  the  more  distressing  symptoms,  and 
the  conviction  of  the  serious  nature  of  the  injury  that 
has  been  sustained,  it  will  be  found,  on  close  enquiry, 
that  there  has  never  been  an  interval,  however  short, 
of  complete  restoration  to  health.  There  have  been 
remissions,  but  no  complete  and  perfect  intermission 
in  the  symptoms.  The  patient  has  thought  himself 
and  has  felt  himself  much  better  at  one  period  than  he 
was  at  another,  so  much  so  that  he  has  been  tempted 
to  try  to  return  to  his  usual  occupation,  but  he  has 
never  felt  himself  well,  and  has  immediately  relapsed  to 
a  worse  state  than  before  when  he  has  attempted  to  do 
work  of  any  kind. 

It  is  by  this  chain  of  symptoms,  which,  through 
fluctuating  in  intensity,  is  yet  continuous  and  unbroken 
that  the  injury  sustained,  and  the  illness  subsequently 
developed,  can  be  linked  together  in  the  relation  of 
cause  and  effect.     ' 


PART  II. 

ON  THE  PATHOLOGY  OF  CONCUSSION  OF  THE   SPINE. 

Having  thus  described  the  various  symptoms  that 
mayarise  from  these  shocks  to  and  concussions  of  the 
spine,  let  us  now  briefly  enquire   into   the   pathological 


158  PATHOLOGY  OF 

conditions  that  lead  to  and  tnat  are  the  direct  causes  of 
these  phenomena. 

I  have  pointed  out  and  discussed  at  some  length  the 
pathological  conditions  that  are  found  within  the  spinal 
canal  in  those  cases  of  more  or  less  complete  paralysis 
that  result  from  direct  and  violent  blows  upon  the  back 
without  fracture  or  dislocation  of  the  bones  entering 
into  the  formation  of  the  vertebral  column.  We  have 
seen  that  in  these  cases  the  signs  of  spinal  lesion  are 
referable  to  extravasation  of  blood  in  various  parts 
within  the  spinal  canal,  to  rupture  of  the  membranes 
of  the  cord,  to  inflammatory  effusions,  or  to  softening 
and  disorganization  of  the  cord  itself. 

In  those  cases  in  which  the  shock  to  the  system  has 
been  general  and  unconnected  with  any  local  and 
direct  implication  of  the  spinal  column  by  external  vio- 
lence, and  in  which  the  symptoms,  as  just  detailed,  are 
less  those  of  paralysis  than  of  disordered  nervous  action 
the  pathological  states  on  which  these  symptoms  are 
dependent  are  of  a  more  chronic  and  less  directly  obvi- 
ous character  than  those  above  mentioned. 

We  should  indeed  be  taking  a  very  limited  view  of 
the  Pathology  of  Concussion  of  the  Spine  if  we  were 
to  refer  all  the  symptoms,  primary  and  remote,  to 
inflammatory  conditions,  either  of  the  vertebral  column, 
the  sheaths  of  the  spinal  nerves,  the  meninges  of  the 
cord,  or  the  substance  of  the  medulla  itself.  Important 
and  marked  as  may  be  the  symptoms  that  are  referable 
to  such  lesions  as  these,  there  are  undoubtedly  states, 
both  local  and  constitutional,  that  are  primarily  depen- 
dent on  molecular  changes  in  the  cord  itself,  on  spinal 
anemia  induced  by  the  shock  of  the  accident  acting 
either  directly  on  the  cord  itself,  or  indirectly,  and  at  a 
later  date,  through  the  medium  of  the  sympathetic,  in 
consequence  of  which  the  blood  distribution  to  the  cord 
becomes  disturbed  and  diminished. 

In  spinal  concussion  there  would  indeed  appear  to 
be  two  distinct  and  indeed  widely  opposed  conditions 
induced,  viz.,  spinal  anaemia  and  spinal  inflammation. 
It  is  of  a  great  importance  to  bear  in  mind  that  these 
two  conditions— entirely  distinct,  and    indeed   opposed 


CONCUSSION  OF  THE   SPINE.  1 59 

as  they  are  pathologically — may  yet  give  rise  to  many 
symptoms  that  have  much  in  common.  There  is, 
however,  this  wide  difference  between  them,  that  "  anae- 
mia of  the  cord  "  is  rather  a  functional  disease — a  clini- 
cal expression  possibly,  more  than  a  well-proved  patho- 
logical fact — whilst,  on  the  other  hand,  the  intra-spinal 
inflammations,  whether  they  affect  the  membranes  of 
the  cord — the  cord  itself  or  both — are  well  recognized 
and  easily  determinable  pathological  states,  the  condi- 
tions connected  with  which  are  positive  organic  lesions 
that  lie  at  the  bottom  of  the  functional  disturbance, 
There  is  then  this  essential  difference  between  the  two 
affections,  that  whereas  the  sign  of  functional  disturb- 
ance may  be  much  the  same  in  both,  in  one  it  is  under- 
laid by  gigantic  disease  and  structural  change,  in  the 
other  by  no  appreciable  pathological  condition. 

We  will  first  consider  the  pathology  of  the  inflamma- 
tory states  of  the  cord  or  its  membranes  that  may  pro- 
ceed from  concussion  of  the  spine,  and  then  consider 
that  condition  of  so-called  spinal  anaemia  that  may  result 
from  '  nervous  shock.'  They  doubtless  consist  mainly 
of  chronic  and  sub-acute  inflammation  of  the  spinal 
membranes,  and  in  chronic  myelitis,  with  such  changes 
in  the  structure  of  the  cord  as  are  the  inevitable  conse- 
quences of  a  long-continued  chronic  inflammatory  con- 
dition developed  by  it. 

It  would  at  first  sight  appear  a  somewhat  remark- 
able circumstance,  that  notwithstanding  the  frequency 
of  the  occurrence  of  cases  of  concussion  of  the  spine  in 
railway  and  other  accidents,  there  should  be  so  few 
instances  on  record  of  examinations  of  the  cord  after 
death  in  these  cases.  But  this  feeling  of  surprise  will 
be  lessened  when  we  reflect  on  the  general  history  of 
these  cases.  If  in  these,  as  in  cases  of  direct  injury  of 
the  spine  with  fracture  or  dislocation,  the  effects  were 
immediate,  severe,  and  often  speedily  fatal,  surgical 
literature  would  abound  with  the  details  of  the  post- 
mortem appearances  presented  by  them,  as  it  does 
with  those  of  the  more  direct  injuries  just  alluded  to. 
But  as  in  these  cases  of  spinal  concussion  the  symptoms 
are  remarkably  slow  in  tlieir  devehjpment  anff  chronic 


l6o  PATHOLOGY   OF 

in  their  progress — as  the  patient  will  live  for  years  in  a 
semi-paralyzed  state,  during  which  time  the  original 
cause  of  his  sufferings  has  almost  been  forgotten — as  he 
seldom  becomes  the  inmate  of  a  hospital — for  the 
chronic  and  incurable  nature  of  his  ailments  does  not 
render  him  so  much  an  object  for  such  a  charity  as  for 
some  asylum,  or  for  private  benevolence — and  as  the 
cause  of  his  death  does  not  become  the  subject  of  in- 
vestigation before  a  coroner's  court,  there  is  little  oppor- 
tunity, reason,  or  excuse  {ox  2.  post-mortem  investigation 
of  that  structure,  w^hich  is  probably  the  one  that  is 
least  frequently  examined  in  the  dead-house,  viz.,  the 
spinal  cord,  as  it  is  the  one  the  correct  pathological 
investigation  of  which  is  attended  by  more  difficulties 
than  that  of  any  other  organ  in  the  body.  Hence  it  is 
that  as  in  most  other  chronic  nervous  diseases  that  are 
only  remotely  fatal — as  in  cases  of  hysteria,  neuralgia, 
and  in  nine-tenths  of  those  of  epilepsy,  we  have  no 
opportunity  of  determining  in  cases  of  concussion  of 
the  spine  very  remotely  fatal,  what  the  anatomy  of  the 
parts  concerned  would  reveal  of  the  real  cause  of  the 
obscure  and  intricate  symptoms  presented  during  life. 
So  rare  ^.r^  post-mortem  examinations  of  these  cases  that 
no  instance  has  occurred  to  me  in  hospital  or  in  private 
practice  in  which  I  could  obtain  one ;  and,  with  one 
exception,  I  can  find  no  record  in  the  transactions  of 
societies,  or  in  the  periodical  literature  of  the  day  of  any 
such  instance. 

The  only  case,  indeed,  on  record  with  which  I  am 
acquainted,  in  which  a  post-moi'tem  examination  has 
been  made  of  the  spinal  cord  of  a  person  who  had  actu- 
ally died  from  the  remote  effects  of  concussion  of  the 
spine  from  a  railway  collision,  is  one  that  was  published 
in  the  "  Transactions  of  the  Pathological  Society  "  by 
Dr.  Lockhart  Clarke.  The  patient,  who  had  been  under 
the  care  of  Mr.  Gore,  of  Bath,  by  whom  the  preparation 
was  furnished,  was  a  middle-aged  man,  52  at  the  time 
of  death,  of  active  business  habits.  He  had  been  in  a 
railway  collision,  and,  without  any  sign  of  external 
injury,  fracture,  dislocation,  wound,  or  bruise,  began  to 
manifest  the  usual  nervous  symptoms.     He  very  gradu- 


CONCUSSION   OF   THE   SPINE.  l6l 

ally  became  partially  paralyzed  in  the  lower  extremities, 
and  died  three  years  and  a  half  after  the  accident. 

Mr.  Gore  has  most  kindly  furnished  me  with  the  fol- 
lowing particulars  of  the  case.  Immediately  after  the 
collision  the  patient  walked  from  the  train  to  the  sta- 
tion close  at  hand.  He  had  received  no  external  sisrn 
of  injury — no  contusions  or  wounds,  but  he  complained 
of  a  pain  in  his  back.  Being  most  unwilling  to  give  in, 
he  made  every  effort  to  get  about  in  his  business,  and 
did  so  for  a  short  time  after  the  accident,  though  with 
much  distress.  Numbness  and  a  want  of  power  in  the 
muscles  of  the  lower  limbs  gradually,  but  steadily 
increasing,  he  soon  became  disabled.  His  gait  became 
unsteady,  like  that  of  a  half-intoxicated  person.  There 
was  great  sensitiveness  to  external  impressions,  so  that 
a  shock  against  a  table  or  chair  caused  great  distress. 
As  the  patient  was  not  under  Mr.  Gore's  care  from  the 
first,  and  as  he  only  saw  the  case  for  the  first  time  about 
a  year  after  the  accident,  and  then  at  intervals  up  to 
the  time  of  death,  he  has  not  been  able  to  inform  me  of 
the  precise  time  when  the  paralytic  symptoms  appeared  ; 
but  he  says  that  this  was  certainly  within  less  than  a 
year  of  the  time  of  the  occurrence  of  the  accident.  In 
the  latter  part  of  his  illness  some  weakness  of  the  upper 
extremities  became  apparent,  so  that  if  the  patient  was 
off  his  guard  a  cup  or  a  glass  would  slip  from  his  fingers. 
He  could  barely  walk  with  the  aid  of  two  sticks,  and  at 
last  was  confined  to  his  bed.  His  voice  became  thick, 
and  his  articulation  imperfect.  There  was  no  paralysis 
of  the  sphincter  of  the  bladder  until  about  eighteen 
months  before  his  death,  when  the  urine  became  pale 
and  alkaline,  with  muco-purulent  deposits.  In  this  case 
the  symptoms  were  in  some  respects  not  so  severe  as 
usual,  there  was  no  very  marked  tenderness  or  rigidity 
of  the  spine,  nor  were  there  any  convulsive  movements. 

The  cord  was  carefully  examined  by  Dr.  Lockhart 
Clarke,  by  whom  the  case  has  been  published.^ 

On  examination,  traces  of  chronic  inflammation  were 
found  in  the  arachnoid  and  the  cortical  substance  of  the 


*"  Transactions  of  the   Pathological  Society  of  London,"  1866,  vol. 
jcvii. 


l62  PATHOLOGY   OF 

brain.  The  spinal  meninges  were  greatly  congested, 
and  exudative  matter  had  been  deposited  upon  the  sur- 
face of  the  cord.  The  cord  itself  was  much  narrowed 
in  its  antero-posterior  diameter,  so  that  in  many  places 
this  was  not  more  than  half  of  the  transverse  diameter. 
This  was  particularly  the  case  in'  the  cervico-dorsal 
region.  The  narrowing  was  owing  to  absorption  of  the 
posterior  columns,  which,  of  all  the  white  columns,  were 
exclusively  the  seat  of  disease.  These  had  not  only  to 
a  great  extent  disappeared,  but  the  remains  were  of  a 
dark-brownish  color,  and  had  undergone  important 
structural  changes.  This  case  is  of  remarkable  interest 
and  practical  value,  as  affording  evidence  of  the  changes 
that  take  place  in  the  cord  under  the  influence  of  "  con- 
cussion of  the  spine "  from  a  railway  accident.  Evi- 
dences of  chronic  meningitis — cerebral  as  well  as  spinal 
— of  chronic  myelitis,  w^th  subsequent  atrophy,  and 
other  organic  changes  dependent  on  mal-nutrition  of 
the  affected  portion  of  the  cord  being  manifest.* 

It  is  well  known  that  two  distinct  forms  of  chronic 
or  subacute  inflammation  may  affect  the  contents  of  the 
spinal  canal  as  the  results  of  injury  or  of  idiopathic  dis- 
ease, viz.,  inflammation  of  the  membranes  and  inflam- 
mation of  the  cord  itself. 

In  spinal  meningitis  the  usual  signs  of  inflammatory 
action  in  the  form  of  vascularization  of  the  membranes 
is  met  with.     The  meningo-rachidian  veins  are  turgid 

*  The  detailed  report  of  the  examination  made  by  Dr.  Lockhart 
Clarke  is  so  valuable  that  I  give  it  in  full : — 

"  On  examining  the  spinal  cord,  as  it  vi^as  sent  to  me  by  Mr.  Gore,  I 
found  that  ihe  membranes  at  some  parts  were  thickened,  and  adherent 
at  others,  to  the  surface  of  the  vi^hite  columns.  In  the  cord  itself,  one 
of  the  most  striking  changes  consisted  in  a  diminution  of  the  antero- 
posterior diameter,  which,  in  many  places,  was  not  more  than  equal  to 
half  the  transverse.  This  was  particularly  the  case  in  the  upper  portion 
of  the  cervical  enlargement,  where  the  cord  was  consequently  much  flat- 
tened from  behind  forward.  On  making  sections,  I  was  surprised  to 
find  that  of  all  the  white  columns,  the  posterior  were  exclusively  the  seat 
of  disease.  These  columns  were  darker,  browner,  denser,  and  more 
opaque  than  the  antero  lateral ;  and  when  they  were  examined,  both 
transversely  and  longitudinally,  in  their  preparations  under  the  micros- 
cope, this  appearance  was  found  to  be  due  to  a  multitude  of  compound 
granular  corpuscles,  and  isolated  granules,  and  to  an  exuberance  of  wavy 
fibrous-tissue  disposed  in  a  longitudinal  direction,     It  was  very  evident 


CONCUSSION   OF  THE   SPINE.  163 

with  blood,  and  the  vessels  of  the  pia  mater  are  found 
much  injected,  sometimes  in  patches,  at  others  uni- 
formly so.  Serous  fluid,  reddened  and  clear,  or  opaque 
from  the  admixture  of  lymph,  may  be  found  largely 
effused  in  the  cavity  of  the  arachnoid. 

Ollivier*  states  that  one  of  the  most  constant  signs 
of  chronic  spinal  meningitis  is  adhesion  between  the 
serous  lamina  that  invests  the  dura  mater  and  that 
which  corresponds  to  the  spinal  pia  mater.  This  he 
says  he  has  often  observed,  and  especially  in  that  form  of 
the  disease  which  is  developed  as  the  result  of  a  lesion 
of  the  vertebrae.  He  has  also  seen  rough  cartilaginous 
(fibroid  ?)  laminae  developed  in  the  arachnoid.  Lymph 
also  of  a  puriform  appearance  has  often  been  found 
under  the  arachnoid,  between  it  and  the  pia  mater. 

In  distinguishing  the  various  pathological  appear- 
ances presented  by  fatal  cases  of  chronic  spinal  menin- 
gitis, Ollivier  makes  the  very  important  practical  remark 
— the  truth  of  which  is  fully  carried  out  by  a  consider- 
ation of  the  cases  related  in  Lectures  II  and  III — that 
spinal  meningitis  rarely  exists  without  there  being  at 
the  same  time  a  more  or  less  extensive  inflammation 
of  the  cerebral  meninges ;  and  hence,  he  says,  arises  the 
difficulty  of  determining  with  precision  the  symptoms 
that  that  are  special  to  inflammation  of  the  membranes 
of  the  spinal  cord. 

When  myelitis  occurs,  the  inflammation  attacking 
the  substance  of  the  cord  itself,  the  most  usual  patho- 
logical condition  met  with  is  softening  of  its  substance, 

that  many  of  the  nerve-fibres  had  been  replaced  by  this  tissue,  and  that 
at  certain  spots  or  tracts,  which  were  more  transparent  than  others, 
especially  along  the  sides  of  the  posterior  median  fissures,  they  had 
wholly  disappeared.  Corpora  amylacea,  also,  were  thickly  interspersed 
through  the  same  columns,  particularly  near  the  central  line. 

"  The  extremities  of  the  posterior  horns  contained  an  abundance  of  iso- 
lated granules  like  those  in  the  columns  ;  and  in  some  sections  the  trans- 
verse commissure  was  somewhat  damaged  by  disintegration.  The 
anterior  cornua  were  decidedly  smaller  than  natural,  and  altered  in 
shape,  but  no  change  in  structure  was  observed." 

Dr.  Clarke  observes  that  the  appearances  presented  by  the  cord  bore  a 
striking  resemblance  in  the  limitations  of  the  lesion  to  the  white  sub. 
stance  to  what  is  met  with  in  Locomotor  Ataxy. 

*  Vol.  ii,  p.  237. 


164  PATHOLOGY   OF 

with  more  or  less  disorganization  of  its  tissue.  This 
softening  of  the  cord  as  a  consequence  of  its  inflamma- 
tion may,  according  to  Ollivier,  occupy  very  varying 
extent  of  its  tissue.  Sometimes  the  whole  thickness  of 
the  cord  is  affected  at  one  point,  sometimes  one  of  the 
lateral  halves  in  a  vertical  direction  is  affected  ;  at  other 
times  it  is  most  marked  in  or  wholly  confined  to  its 
anterior  or  its  posterior  aspect,  or  the  grey  central  por- 
tion may  be  more  affected  than  the  circumferential  part. 
Then,  again,  these  changes  of  structure  may  be  limited 
to  one  part  only — to  the  cervical,  the  dorsal,  or  the  lum- 
bar. It  is  very  rare  indeed  that  the  whole  length  of 
the  cord  is  affected.  The  most  common  seat  of  the 
inflammatory  softening  is  the  lumbar  region ;  next  in 
order  of  frequency  the  cervical.  In  very  chronic  cases 
of  myelitis  the  whole  of  the  nervous  substance  disap- 
pears, and  nothing  but  connective  tissue  is  left  behind 
at  the  part  affected. 

Ollivier  makes  the  important  observation  that  when 
myelitis  is  consecutive  to  meningitis  of  the  cord,  the 
inflammatory  softening  may  be  confined  to  the  white 
substance. 

But  though  softening  is  the  ordinary  change  that 
takes  place  in  a  cord  that  has  been  the  seat  of  chronic 
inflammation,  yet  sometimes  the  nervous  substance 
becomes  indurated,  increased  in  bulk,  more  solid  than 
natural,  and  of  a  dull  white  color,  like  boiled  white  of 
egg.  This  induration  of  the  cord  may  coexist  with 
spinal  meningitis,  with  congestion,  and  increased  vascu- 
larization of  the  membranes.  The  case  of  the  Count 
de  Lordat  is  an  instance  of  this  induration  and  enlarge- 
ment of  the  substance  of  the  cord,  and  others  of  a  similar 
nature  are  recorded  by  Portal,  Ollivier,  and  Abercrombie. 

It  is  important  to  observe  that  although  spinal  menin- 
gitis and  myelitis  are  occasionally  met  with  distinct  and 
separate  from  each  other,  yet  that  they  most  frequently 
coexist.  When  existing  together,  and  even  arising 
from  the  same  cause,  they  may  be  associated  with  each 
other  in  very  varying  degrees.  In  some  cases  the  symp- 
toms of  meningitis,  in  others  those  of  myelitis,  are  most 
marked,  and  after  death  the  characteristic  appearances 


CONCUSSION  OF  THE  SPINE.  165 

present  a  predominance  corresponding  to  that  assumed 
by  their  effects  during  life. 

I  have  given  but  a  very  brief  sketch  of  the  patho- 
logical appearances  that  are  usually  met  with  in  spinal 
meningitis  and  in  myelitis,  and  it  is  not  my  intention  in 
these  Lectures  to  occupy  your  attention  with  an  elabo- 
rate inquiry  into  the  pathology  of  these  affections,  but 
rather  to  consider  them  in  their  clinical  relations. 

I  wish  now  to  direct  your  attention  to  the  symptoms 
that  are  admitted  by  all  writers  on  diseases  of  the  ner- 
vous system  to  be  connected  with  and  dependent  upon 
the  pathological  conditions  that  I  have  just  detailed  to 
you,  and  to  direct  your  attention  to  a  comparison  be- 
tween these  symptoms  and  those  that  are  described  in 
the  various  cases  that  I  have  detailed  to  you  as  charac- 
teristic of  "  Concussion  of  the  Spine  "  from  slight  inju- 
ries and  general  shocks  of  the  body. 

The  symptoms  that  I  have  detailed  arrange  themselves 
in  three  groups : 

1st.  The  cerebral  symptomSo 

2d.  The  spinal  symptoms. 

3d.  Those  referable  to  the  limbs. 

In  comparing  the  symptoms  of  *'  Concussion  of  the 
Spine "  arising  from  railway  and  other  accidents,  as 
detailed  in  the  cases  I  have  related,  with  those  that  are 
given  to  and  accepted  by  the  profession  as  dependent 
on  spinal  meningitis  and  myelitis  arising  from  other 
causes,  I  shall  confine  the  comparison  of  my  cases  to 
those  related  by  Abercrombie  and  OUivier.  And  I  do 
this  for  two  reasons ;  first,  because  the  works  of  these 
writers  on  diseases  of  the  spinal  cord  are  universally  re- 
ceived as  the  most  graphic  and  classical  on  the  subject 
of  which  they  treat  in  this  country  and  in  France  ;  and, 
secondly,  because  their  descriptions  were  given  to  the 
world  before  the  railway  era,  and  consequently  could  in 
no  way  have  been  influenced  by  accidents  occurring  as 
a  consequence  of  modern  modes  of  locomotion. 

I.  With  respect  to  the  cerebral  symptoms.  It  will 
be  observed  that  in  most  of  the  cases  that  I  have  related 
there  was  more  or  less  cerebral  disturbance  or  irrita- 
tion, as  indicated  by  headache,  confusion  of  thought. 


l66  PATHOLOGY   OF 

loss  of  memory,  disturbance  of  the  organs  of  sense,  irri- 
tability of  the  eyes  and  ears,  etc. ; — symptoms,  in  fact, 
referable  to  subacute  cerebral  meningitis  and  arachnitis. 

On  this  point  the  statement  of  Ollivier  is  most  pre- 
cise and  positive.  He  says  that  it  is  rare  to  find  in- 
flammation of  the  spinal  membrane  limited  to  the  ver- 
tebral canal,  but  that  we  see  at  the  same  time  a  more  or 
less  intense  cerebral  meningitis.  In  the  cases  that  he 
relates  of  spinal  meningitis,  he  makes  frequent  refer- 
ence to  these  cerebral  symptoms — states  that  they  often 
complicate  the  case  so  as  to  render  the  diagnosis  diffi- 
cult, especially  in  the  early  stages.  In  the  post-mortem 
appearances  that  he  details  of  patients  who  have  died 
of  spinal  meningitis,  he  describes  the  morbid  conditions 
met  with  in  the  cranium,  indicative  of  increased  vascu- 
larity and  inflammation  of  the  arachnoid.  This  com- 
plication of  cerebral  with  spinal  meningitis  is  nothing 
more  than  we  should  expect.  It  may  arise  from  two 
ways :  Either  from  the  head  having  been  injured  at 
the  same  time  and  in  the  same  way  as  the  spine,  or  as 
a  simple  consequence  of  inflammation  running  along  a 
continuous  membrane.  In  both  the  fatal  cases  of  men- 
ingitis of  the  spine  recorded  by  Abercrombie,  evidences 
of  intra-cranial  mischief  are  described. 

2.  The  spinal  symptoms  that  occurred  in  the  cases 
of  "  Concussion  of  the  Spine  "  which  I  have  related, 
consisted  briefly  of  pain  at  one  or  more  points  of  the 
spine,  greatly  increased  on  pressure,  and  on  movement 
of  any  kind,  so  as  to  occasion  extreme  rigidity  of  the 
vertebral  column. 

Ollivier  says  that  one  of  the  most  characteristic 
signs  of  spinal  meningitis  is  pain  in  the  spine,  which  is 
most  intense  opposite  the  seat  of  inflammation.  This 
pain  is  greatly  increased  by  movement  of  any  kind,  so 
that  the  patient,  fearing  the  slightest  displacement  of 
the  spine,  preserves  it  in  an  absolute  state  of  quies- 
cence. The  pain  is  usually  accompanied  by  muscular 
rigidity.  It  remits,  being  sometimes  much  more  severe 
than  at  others,  and  occasionally  it  even  disappears 
entirely.  According  to  some  observers,  the  pain  of 
spinal   meningitis   is   increased   by   pressure.     But  the 


CONCUSSION   OF   THE   SPINE.  167 

correctness  of  this  observation  is  doubted  by  Ollivicr, 
who  says  that  in  chronic  myelitis  there  is  a  painful  spot 
in  the  spine  where  the  pain  is  increased  on  pressure, 
and  he  looks  upon  this  as  indicative  of  inflammation  of 
the  cord  rather  than  of  the  membranes. 

3.  The  third  group  of  symptoms  dependent  on  con- 
cussion of  the  spine  are  those  referable  to  the  limbs. 
They  have  been  described,  and  may  briefly  be  stated  to 
consist  in  painful  sensations  along  the  course  of  the 
nerves,  followed  by  more  or  less  numbness,  tingling, 
and  creeping ;  some  loss  of  motor  power  affecting  one 
or  more  of  the  limbs,  and  giving  rise  to  peculiarity  and 
unsteadiness  of  gait.     No  paralysis  of  the  sphincters. 

These  are  the  very  symptoms  that  are  given  by 
Ollivier  and  others  as  characteristic  of  spinal  meningi- 
tis, but  more  particularly  of  myelitis. 

In  spinal  meningitis,  says  Ollivier,  there  is  increased 
sensibility  in  different  parts  of  the  limbs,  extending 
along  the  course  of  the  nerves,  and  augmented  by  the 
most  superficial  pressure.  These  pains  are  often  at 
first  mistaken  for  rheumatism.  There  is  often  also 
more  or  less  rigidity  and  contraction  of  the  muscles. 

In  myelitis  the  sensibility  is  at  first  augmented,  but 
after  a  time  becomes  lessened,  and  gives  way  to  various 
uneasy  sensations  in  the  limbs,  such  as  formications,  a 
feeling  as  if  the  limb  was  asleep  {engoiirdissement). 
These  sensations  are  first  experienced  in  the  fingers  and 
toes,  and  thence  extend  upwards  along  the  limbs. 

These  sensations  are  most  complained  of  in  the 
morning  soon  after  leaving  bed.  They  intermit  at 
times,  fluctuating  in  intensity,  and  in  the  early  stages 
are  lessened  after  exercise,  when  the  patient  feels  better 
and  stronger  for  a  time,  but  these  attempts  are  followed 
by  an  aggravation  of  the  symptoms.  Some  degree  of 
paralysis  of  movement,  of  loss  of  motor  power,  occurs 
in  certain  sets  of  muscles — or  in  one  limb.  Thus  the 
lower  limbs  may  be  singly  or  successively  affected 
before  the  upper  extremities,  or  vice  versa.  Occasion- 
ally this  loss  of  power  assumes  a  hemiplegic  form.  All 
this  will  vary  according  to  the  seat  and  the  extent  of 
the  myelitis. 


1 68  PATHOLOGY  OF 

There  is  usually  constipation  in  consequence  of  loss 
of  power  in  the  lower  bowel.  It  is  very  rare  that  the 
bladder  is  early  affected,  the  patient  having  voluntary 
control  over  that  organ  until  the  most  advanced  stages 
of  the  disease,  towards  the  close  of  life,  when  the 
softening  of  the  cord  is  complete. 

Ollivier  remarks,  that  in  chronic  myelitis  patients 
often  complain  of  a  sensation  as  of  a  cord  tied  tightly 
round  the  body. 

The  gait  {demarche)  of  patients  affected  with  chronic 
myelitis  is  peculiar.  It  is  unsteady,  rolling,  like  that 
of  a  partially  intoxicated  man.  The  foot  is  raised 
with  difficulty,  the  toe's  are  sometimes  depressed  and 
at  others  they  are  raised,  and  the  heel  drags  in  walking. 
The  body  is  kept  erect  and  carried  somewhat  backwards. 

If  we  take  any  one  symptom  that  enters  into  the 
composition  of  these  various  groups,  we  shall  find  that 
it  is  more  or  less  common  to  various  forms  of  disease 
of  the  nervous  system^  But  if  we  compare  the  groups 
of  symptoms  that  have  just  been  detailed,  their  pro- 
gressive development  and  indefinite  continuance,  with 
those  which  are  described  by  Ollivier  and  other  writers 
of  acknowledged  authority  on  diseases  of  the  nervous 
system,  as  characteristic  of  spinal  meningitis  and 
myelitis,  we  shall  find  that  they  mostly  correspond  with 
one  another  in  every  particular — so  closely,  indeed,  as 
to  leave  no  doubt  that  the  whole  train  of  nervous  phe- 
nomena arising  from  shakes  and  jars  of  or  blows  on  the 
body,  and  described  as  characteristic  of  so-called  ''  Con- 
cussion of  the  Spine,"  are  in  reality  due  to  chronic 
inflammation  of  the  spinal  membranes  and  cord.  The 
variation  in  different  cases  being  referable  partly  to 
whether  meningitis  or  myelitis  predominates,  and  in  a 
great  measure  to  the  exact  situation  and  extent  of 
the  intra-spinal  inflammation,  and  to  the  degree  to 
which  its  resulting  structural  changes  may  have  devel- 
oped themselves  in  the  membranes  or  cord. 

We  will  now  proceed  briefly  to  consider  the  second 
pathological  state  to  which  the  symptoms  of  many  of 
these  cases  of  Concussion  of  the  Spine  from  indirect 
and  often  slight  injuries  may  be  referred — I  mean  that 


CONCUSSION   OF  THE   SPINE.  169 

state  which  is  now  recognized  as  Spinal  Anaemia.  And 
especially  the  so-call  "Anaemia  of  the  Posterior  Col- 
umns of  the  Cord." 

As  has  already  been  stated,  this  is  a  condition  v/hich 
we  rather  recognize  clinically  than  pathologically,  by 
analogy  than  by  direct  post-mortem  demonstration,  by 
therapeutical  rather  than  by  physiological  tests.  But 
yet  it  is  a  condition  that  is  now  fully  recognized  as 
probable,  in  lieu  of  positive  evidence,  by  the  best  and 
most  modern  writers  on  nervous  diseases,  and  one  the 
probable  existence  of  which  we  may  accept. 

I  have  given  you  the  views  of  Ollivier  and  Aber- 
crombie  on  the  true  pathological  state  of  myelitis  and 
meningitis.  Let  me  refer  you  to  those  of  the  most 
recent  writer  on  nervous  diseases,  Hammond,  of  New 
York,  on  the  subject  of  Spinal  Anaem'a.^  In  his  work 
you  will  find  a  very  complete  and  exhaustive  account  of 
the  idiopathic  forms  of  it  which  in  many  respects  closely 
resemble  the  traumatic  which  we  are  now  considering. 

The  Functional  Paralysis  or  Paresis  met  with  in  Spi- 
nal Anaemia  is  a  very  common  sequence  of  Spinal 
Concussion.  It  chiefly  affects  the  lower  extremities — 
one  or  both — but  may  be  hemiplegic.  There  is  complete 
anaesthesia  involving  large  tracts  of  the  surface  of  the 
limbs  and  body,  usually  without  reference  to  any  dis- 
tinct nerves  or  to  their  anatomical  distribution.  The 
skin  is  cold  and  pallid.  Motor  power  power  may  be 
completely  lost,  or  it  may  be  diminished  or  even  absent 
in  one  group  of  muscles  and  not  in  another.  There  is 
diminution  or  even  complete  loss  of  electric  irritability 
in  the  affected  muscles.  In  this  condition  there  are 
usually  some  of  the  more  general  symptoms  of  hys- 
teria ;  notably  the  "globus "  or  the  emotional  state. 
There  is  also  very  commonly  either  incontinence  or 
retention  of  urine.  I  have  known  no  urine  passed  for 
three  or  four  days  in  such  cases,  and  yet  on  introducing 
a  catheter  the  bladder  has  been  found  to  contain  only 
perhaps  20  to  24  ounces — a  proof  that  the  secretion  of 

*"0n   Diseases  of  the  Nervous  System,"  by  Dr.    Hamm  ).  d.   New 
York,  1873. 


I/O  ANEMIA 

the  kidneys  is  arrested  as  well  as  the  expulsive  power 
of  the  bladder  lost. 

In  this  Paresis  there  is  no  atrophy  or  rigidity  of 
muscles ;  the  limbs,  though  cold,  motionless,  and  more 
or  less  devoid  of  sensation,  do  not  waste  ;  and  however 
long  the  patient  lies  in  bed  no  bedsore  forms.  Recovery 
eventually  occurs ;  often  very  rapidly,  and  possibly 
under  the  influence  of  some  mental  emotion — by  the 
grief  of  a  death,  by  the  necessity  for  exertion.  By 
these  various  signs  may  Paresis  or  functional,  be  diag- 
nosed from  true  or  organic.  Paralysis. 


LECTURE  VIII. 

ON  SPINAL  ANEMIA,  HYSTERIA,  SHOCK  AND  UNCON- 
SCIOUSNESS AS  CONSEQUNCES  OF  CONCUSSION  OF 
THE   SPINE. 

Aaemia  of  the  spinal  cord  is  that  condition  which  has 
long  been  recognized  by  physicians  in  one  of  its  forms 
as  giving  rise  to  a  group  of  symptoms  which  collec- 
tively are  known  familiarly  as  constituting  the  disease 
called  "  Spinal  Irritability."  Most  commonly  the  dis- 
ease stops  here,  but  there  is  another  form  in  which  it 
advances  beyond  the  stage  of  irritation  and  enters  that 
of  paralysis.  The  symptoms  of  this  condition  are  those 
of  exhaustion,  associated,  as  all  conditions  of  nervous 
exhaustion  are  apt  to  be,  with  neuralgic  pains  or  hyper- 
aesthesia,  which  often  assumes  such  prominence  as  to 
overshadow  the  allied  conditions  of  a  paralytic  character. 
These  symptoms  may  develop  themselves  suddenly  after 
the  receipt  of  an  injury  of  the  spine,  more  especially  in 
persons  who  by  a  previous  state  of  weak  or  ill  health 
are  predisposed  to  their  occurrence  ;  or  they  may  occur 
more  gradually  in  those  whose  health  is  broken  down, 
whose  nutrition  is  impaired,  and  who  consequently 
become  anaemic  as  the  result  of  disturbances  of  the 
system  induced  by  the  injury  to  which  they  have  been 
subjected.  It  is  a  condition  that  is  most  apt  to  occur 
in  the  young,  more  especially  in  women,  under  the  age 


OF  THE   SPINE.  I71 

of  35.  I  have,  however,  seen  many  unequivocal  instances 
of  this  condition  in  men,  and  in  individuals  of  both  sexes 
several  years  older  than  this. 

The  symptoms  of  spinal  anaemia  are  as  follows: — 
There  is  always,  and  as  the  most  prominent  symptom, 
considerable  pain  in  the  spine.  The  pain  in  the  spinal 
column  is  greatly  increased  by  pressure,  whether  super- 
ficial or  deep  ;  by  flexion,  rotation,  or  downward  pres- 
sure on  the  spine.  It  is  augmented  by  pressing  deeply 
into  the  inter-vertebral  spaces  on  either  side  of  the 
spine,  and  by  the  application  of  a  hot  sponge.  The 
pain  is  not  much,  if  at  all,  complained  of  when  the  body 
is  at  rest,  or  when  the  back  is  not  pressed  upon.  It  is 
more  of  the  nature  of  tenderness  on  pressure  than  of 
actual  permanent  pain.  This  tenderness  may  be  lim- 
ited to  one  spot  in  the  spine,  and  if  so,  is  usually  seated 
in  the  cervico-dorsal  region.  It  may  occupy  several 
points,  or  it  may  extend  over  the  whole  vertebral  col- 
umn. It  is  always  associated,  when  traumatic — and  I 
am  only  speaking  now  of  spinal  anaemia,  the  result  of 
injury — with  cutaneous  hyperaesthesia,  often  of  a  very 
intense  character,  diffused  more  or  less  extensively  over 
the  posterior  part  of  the  back,  usually  as  far  as  the 
lateral  median  lines.  In  fact  it  corresponds  exactly  to 
the  distribution  of  the  superficial  branches  of  the  pos- 
terior primary  divisions  of  the  dorso-spinal  nerves.  This 
hyperaesthesia  is  often  so  intense  that  the  mere  approach 
of  the  finger  will  occasion  involuntary  shrinking  on  the 
part  of  the  patient,  that  it  would  almost  appear  as  if 
the  dress  rather  than  the  skin  were  the  seat  of  the 
exalted  sensibility.  But  intense  as  it  may  be,  when  the 
patient's  attention  is  fixed  on  the  approach  of  the  sur- 
geon's finger,  yet  if  his  mind  is  occupied  by  having  his 
thoughts  directed  to  other  matters,  the  hand  may  be 
placed  upon  the  back  and  carried  down  the  spine  with- 
out the  slightest  sign  of  suffering.  It  is  much  the  same 
with  movements  of  the  body.  If  the  surgeon  flexes  or 
rotates  the  spine,  in  order  to  test  the  existence  of  pain, 
the  patient  will  cry  out,  writhe  with  agony,  and  com- 
plain loudly  of  the  torture  inflicted  upon  him  ;  but  if 
his  attention  is  otherwise  engaged  he  will  rise  off  the 


172  ANyEMIA 

couch  on  which  he  is  lying,  stoop,  dress  and  undress 
himself  without  the  slightest  sign  of  suffering.  This, 
which  often  throws  suspicion  on  the  bona  fides  of  the 
patient,  must  not,  for  reasons  that  will  be  given  in  the 
Lecture  on  Diagnosis,  be  taken  as  an  evidence  of  ma- 
lingering. That  he  does  suffer  pain  when  his  attention 
is  directed  to  the  part  that  is  touched  or  moved  there 
can  be  no  doubt ;  that  this  pain  is  not  permanent,  or 
that  it  disappears  w^hen  his  attention  is  actively  engaged 
elsewhere,  and  is  as  much  dependent  on  the  patient's 
mental  condition  as  upon  the  state  of  the  spinal  cord, 
is  equally  certain. 

In  the  more  intense  cases  of  anaemia  of  the  spinal 
cord  there  is  paralysis,  more  or  less  complete,  of  sen- 
sation, and  often  quite  complete  of  motion  in  the  lower 
extremities.  Below  a  certain  level  in  the  dorso-lumbar 
region,  in  the  greater  part,  if  not  in  the  whole,  the 
nervous  system  appears  to  be  completely  exhausted, 
and  its  action  almost  entirely  suspended.  It  is  equally 
incapable  of  receiving  and  transmitting  impressions. 
The  legs  and  feet  are  cold  ;  there  is  no  reflex  sensi- 
bility or  movement  in  them;  they  are  not  susceptible 
to  the  electric  stimulus,  either  as  regards  muscular  irri- 
tability or  cutaneous  sensibility.  They  are,  of  course, 
utterly  unable  to  support  the  patient.  The  knees  bend 
under  him  in  a  flaccid  manner  if  an  attempt  is  made  to 
place  him  on  his  feet,  and  the  legs  fall  heavily  and  life- 
lessly on  the  bed  when  raised  from  it.  But  notwith- 
standing all  this  local  nervous  exhaustion,  it  will  be 
found  that  the  sphincters  are  not  paralyzed,  and  the 
general  health  though  enfeebled,  may  be  fairly  good. 
The  intelligence  is  usually  perfect,  though  the  brain  and 
the  eyes  easily  become  fatigued,  and  the  patient  is  thus 
equally  incapable  of  sustained  intellectual  effort,  or  of 
continuous  reading.  The  condition,  in  fact,  is  one  of 
complete  exhaustion  of  the  spinal  system  below  a  cer- 
tain level,  that  level  usually  corresponding  with  a  line 
drawn  round  the  body  from  the  tenth  dorsal  vertebra. 
The  condition  of  the  inferior  divisions  of  the  cord,  and 
of  the  nerves  of  the  lower  extremities  in  spinal  anaemia, 
\^xy  closely  resemble  the  perversion  and  suspension  of 


OF  THE   SPINE.  173 

functions  met  with  in  certain  of  the  sensory  nerves  in 
the'exhaustion  of  the  cerebral  anaemia.  The  impair- 
ment of  vision  amounting  at  last  to  complete  amaurosis, 
the  tinnitus  aurium  going  on  to  deafness  of  one  or  both 
ears  after  prolonged  lactation  and  profuse  haemmor- 
rhages,  are  of  this  kind.  Purely  functional  conditions 
dependent  on  the  infected  nerve  being  incapable  alike 
of  the  reception  and  the  transmission  of  sensory  im- 
pressions. 

As  I  have  already  remarked,  this  condition,  which  Vv^e 
call  anaemia  of  the  cord,  is  scarcely  a  pathological  one. 
It  is  never  fatal,  and  hence  no  opportunity  has  been 
afforded  to  pathologists  of  examining  the  condition  of 
the  parts  after  death.  It  is  rather  by  clinical  inference 
than  by  positive  pathological  observation  that  such  a 
state  can  be  termed  one  of  anaemia ;  and  in  this  uncer- 
tainty as  to  its  true  pathology,  it  may  perhaps  scarcely 
be  desirable  to  attempt  to  give  an  explanation  of  the 
method  by  which  such  a  condition  of  the  cord  is  brought 
about.  Whether  it  is  by  a  concussion  or  vibratory  jar 
in  consequence  of  which  its  molecular  condition  is  so 
disturbed  that  its  functions  become  for  a  time  perverted 
or  suspended,  or  whether,  as  may  not  improbably  be 
the  case,  the  primary  lesion  has  been  inflicted  upon  the 
sympathetic  system  of  nerves,  in  consequence  of  which 
the  vascular  supply  to  the  cord  may  have  become  inter- 
fered^ with,  and  the  symptoms  that  have  just  been 
described  have  directly  resulted  from  diminution  of 
arterial  blood  transmitted  to  it,  as  the  result  of  the  dis- 
turbance of  the  vasi-motor  action  of  the  sympathetic  is 
uncertain.  That  the  sympathetic  is  disturbed  in  many 
of  these  cases  would  appear  to  be  probable,  from  the 
fact  that  this  so-called  spinal  anaemia  is  frequently  asso- 
ciated with  derangement  of  function  of  the  abdominal  or 
thoracic  organs,  as  shown  by  palpitations,  vomitings,  etc. 
^  We  will  now  proceed  to  the  consideration  of  a  con- 
dition of  the  nervous  system  that  occasionally  occurs 
as  a  result  of  spinal  concussion,  which  appears  in  its 
clinical  history,  in  its  symptoms,  and  probably  in  its 
pathology,  closely  allied  to  anaemia  of  the  cord,  and 
which,  for  want  of  a  better  name,   we   are  apt  to  call 


1/4  AN.^MIA 

"  Hysteria,"  that  word  which  serves  as  a  cloak  to  ignor- 
ance, and  which  simply  means  a  group  of  symptoms  all 
subjective  and  each  one  separately  common  to  many 
morbid  states. 

But  before  proceeding  to  speak  of  hysteria  as  a 
result  of  concussion  of  the  spine,  let  me  say  a  few 
words  about  the  different  varieties  of  nervous  shock, 
leading  up  to  complete  unconsciousness,  that  may  result 
from  these  accidents. 

It  is  important  to  observe  that  a  serious  accident  may 
give  rise  to  two  distinct  forms  of  nervous  shocks,  which 
may  be  sufficiently  severe  to  occasion  complete  uncon- 
sciousness. The  first  is  mental  or  moral,  and  the  sec- 
ond purely  physical.  These  forms  of  *'  shock  "  may  be 
developed  separately,  or  they  may  co-exist.  It  is  most 
important,  not  only  so  far  as  a  prognosis  of  the  patient's 
future  state,  but  also  so  far  as  the  recognition  of  his 
immediate  condition  is  concerned,  to  diagnose  between 
these  two,  and  if  co-existing  to  assign  to  each  its  proper 
importance. 

The  mental  or  moral  form  of  unconsciousness  may 
occur  without  the  infliction  of  any  physical  injury,  blow, 
or  direct  violence  to  the  head  or  spine.  It  is  commonly 
met  with  in  persons  who  have  been  exposed  to  compar- 
ative trifling  degrees  of  violence,  who  have  suffered 
nothing  more  than  a  general  shock  or  concussion  of  the 
system.  It  is  probably  dependent  in  a  great  measure 
upon  the  influence  of  fear ;  it  partakes  more  of  the 
character  of  syncope  than  of  the  true  concussion  of  the 
brain,  or  of  that  extreme  depression  of  the  system  that 
is  consequent  upon  the  infliction  of  a  severe  physical 
shock.  It  is  never  followed  by  those  secondary  effects 
that  are  so  commonly  met  with  after  a  shock  has  been 
inflicted  by  a  direct  injury  to  the  head,  spine,  or,  indeed, 
to  the  body  generally.  If  it  is  followed  by  any  after 
symptoms,  these  are  usually  of  an  emotional  and  pos- 
sibly of  an  hysterical  character.  It  will  be  found  that 
as  the  patient  recovers  from  the  immediate  and  primary 
depression  of  the  shock,  he,  or  more  frequently  she, 
becomes  greatly  agitated,  nervous,  or  truly  hysterical, 
often  manifesting  great  excitement,  and  being  soothed 


OF  THE   SPINE.  1 75 

and  pacified  with  difficulty.  This  form  of  shock,  even 
though  it  be  attended  by  unconsciousness,  is  not  fol- 
lowed by  those  after  phenomena  indicative  of  real  or 
organic  lesions  of  the  brain,  the  cord,  and  their  mem- 
branes, which  so  commonly  result  from  physical  shock. 
It  is  this  condition  that  is  so  apt  to  lead  to  an  emo- 
tional state,  which,  for  want  of  a  better  term,  may  be 
called  hysteria. 

This  mental  state  is  one  much  more  frequently  met 
with  amongst  women  than  men ;  but  in  men  it  is  occa- 
sionally found  as  one  of  the  sequelae  of  railway  injuries. 
I  say  of  railway  injuries,  because  it  is  the  rarest  thing 
possible  to  meet  with  it  after  accidents  of  any  other 
kind.  During  a  hospital  practice  of  thirty  years  I  can 
scarcely  recall  to  mind  a  single  case  in  which  the  emo- 
tional or  hysterical  state  that  I  am  obout  to  describe 
has  been  met  with  after,  or  as  a  consequence  of,  any  of 
the  ordinary  accidents  of  civil  life.  But  I  have  seen 
many  instances  of  it  after  railway  concussions.  Is  this 
due  to  the  frantic  terror  which  often  seizes  upon  the 
sufferers  from  railway  collisions,  or  is  it  due  to  some 
peculiarity  in  the  accident,  some  vibratory  thrill  trans- 
mitted through  the  nervous  system  by  the  peculiarity 
of  the  accident  ?  I  am  disposed  to  think  that  terror  has 
much  to  do  with  its  production.  It  must  be  remembered 
that  railway  accidents  have  this  peculiarity,  that  they 
come  upon  the  sufferers  instantaneously  witthout  warn- 
ing or  with  but  a  few  seconds  for  preparation,  and  that 
the  utter  helplessness  of  a  human  being  in  the  midst  of 
the  great  masses  in  motion  renders  these  acci'dents 
peculiarly  terrible.  In  most  ordinary  accidents,  as  in 
a  carriage  accident  from  a  runaway  horse,  the  sufferer 
has  a  few  minutes  to  prepare,  is  enabled  to  collect  his 
energies  in  order  to  make  an  effort  to  save  himself,  and 
does  not  feel  the  utter  hopelessness  of  his  condition  m 
his  struggle  for  life  and  safety.  The  crash  and  confu- 
sion, the  uncertainty  attendant  on  a  railway  collision, 
the  shrieks  of  the  sufferers,  possibly  the  sight  of  the 
victims  of  the  catastrophe,  produce  a  mental  impression 
of  a  far  deeper  and  more  vivid  character  than  is  occa- 
.sioned   by  the  more   ordinary  accidents   of  civil   life. 


176  AN.EMIA 

Hence,  I  think,  the  greater  degree  of  mental  shock  that 
accompanies  them,  and  of  the  hysterical  state  that  is 
apt  to  be  induced  by  them. 

The  symptoms  indicative  of  this  emotional  or  hys- 
terical condition  are  as  follows : — The  patient,  after 
having  been  subjected  to  the  disturbing  influences  of  a 
railway  accident,  by  which  he  has  become  greatly 
alarmed  and  agitated,  but  in  which  he  has  not  received 
any  direct  or  serious  physical  injury,  may,  for  a  few 
hours,  or  even  for  a  day  or  so,  possibly  go  about  his 
business,  but  in  a  constrained  and  unnatural  manner, 
before  the  emotional  symptoms  develop  themselves. 
These  then  manifest  themselves  usually  in  the  first 
instance  by  a  violent  fit  of  sobbing  and  weeping.  He 
becomes  alternately  irritable  and  morose  in  character, 
emotional  to  a  high  degree,  so  that  he  bursts  into  tears, 
sobs  if  spoken  to,  especially  in  a  kind  manner,  and  at 
other  times  becomes  irascible,  and  even  threatens  his 
family  and  those  around  him  with  violence.  He 
becomes  utterly  unfitted  for  business  or  for  the  ordinary 
duties  of  life.  Notwithstanding  these  nervous  symp- 
toms, his  digestive  organs  do  their  duty  naturally  and 
well,  and  his  various  functions  are  healthily  performed. 
He  does  not  lose  flesh,  but  he  has  a  despondent  and 
haggard  look  of  countenance.  It  is  alike  impossible 
to  reason  with  him  or  to  console  him.  He  nurses  his 
symptoms,  and  dwells  upon  his  sufferings,  his  losses, 
and  his  wrongs.  If  he  has  been  struck  on  any  part  of 
the  body,  this  will  usually  become  the  seat  of  pain. 
This  pain  is  diffused  ;  does  not  effect  the  anatomical 
course  of  any  .particular  nerve,  and  consists,  in  a  great 
measure,  of  skin-tenderness.  It  is  usually  the  spine 
that  is  thus  complained  of ;  and  although  the  patient 
suffers  pain,  which  he  describes  in  exaggerated  language 
as  of  the  most  agonizing  and  excruciating  character, 
when  lightly  touched,  not  only  over  the  vertebral 
column  itself,  but  on  almost  any  part  of  the  skin  of 
the  back,  he  will  move  freely,  walk  about,  get  up  and 
sit  down,  dress  and  undress  himself,  without  such 
restrictions  of  his  movements  as  would  necessarily  arise 
from  the  suffering  that  is  the  result  of  organic  disease. 


OF  THE   SPINE.  1 7/ 

There  is  an  obvious  want  of  consistence  between  the 
freedom  of  his  movements   and   the  pain   that  is  com- 
plained of  on  pressure  on   the   affected  part.     So  sensi- 
tive does  he  become  to   the  touch   that  as  soon  as  the 
surgeon  lays  his  finger  upon   his   coat,   before  the  skin 
could  have  been  impressed,   he  will  start  away  as  if  he 
had  been  seriously   hurt,    and   in    some    cases  even  he 
becomes  nervous  and  excited  if  any  person  stands  behind 
him.     There  is,  in  fact,  that  unconscious  exaggeration 
of  symptoms,  and  especially   of  pain,  which  is  common 
to    all    hysterical    people,   that   simulation   or  nervous 
mimicry  of  real  disease  which  has  been  so  well  described 
by  Brodie  and  by  Paget.     This  state  of  things  v/ill  last 
indefinitely  without  any  very  material   change.     There 
may  be  daily  or  weekly  fluctuations,   but  the  patient 
neither  gets  materially  better  nor  worse.     This  state 
will  continue,  indeed,  as  long  as  the  mind  is  impressed 
by  the  prospect  of  impending  litigation.     When  once 
that  has  been  removed,  recovery,  provided  there  be  no 
organic  complication,  will  take  place  so  rapidly  as  to 
lead  to  the  suspicion   that  the  whole   of  the  sufferings 
were  purposely  simulated,   and  that  the  patient  was  a 
malingerer.     This  conclusion  may  possibly  be  correct 
in   some    cases,   but  in   others   it  lis   certainly  unjust. 
Anxiety  of  mind  has  much  to   do  with  the  develop- 
ment of  the  symptoms  that   I   have  just  been  mention- 
ing.    They  arise  in  the  first  instance  from  the  agony  of 
fear  into  which    some    individuals  are    thrown  on  the 
occurrence  ofany  great  catastrophe.     It   is  not  given  to 
everyone  to  be  able  to  preserve  calmness  of  mind  in  the 
midst  of  the  crash  and  confusion   of  a  railway  collision, 
though  it  be  not  of  the  most  serious  nature ;  it  is  not 
given  to  everyone  to  be  one  of  those  ^n\vox^  si  fr actus 
illabatur  orbis,  hnpavidum  ferient  ruincB. 

This  state  is  maintained  by  anxieties  connected  w4th 
the  collapse  of  business,  and  possibly  of  impending 
pecuniary  difficulties  occasioned  by  the  forced  relin- 
quishment of  work  consequent  upon  the  injury  that  the 
patient  has  sustained,  and  it  is  continued  indefinitely  by 
the  harass  of  mind  consequent  on  the  litigation  in  which 
the  sufferer  becomes  involved   in  prosecuting  his  claim 


178  ANEMIA 

for  compensation.  These  anxieties  once  removed,  the 
mental  tone  speedily  becomes  restored,  that  power  of 
self-control  which  has  been  lost  is  regained,  and  the 
emotional  condition  and  its  concomitant  phenomena, 
which  are  consequent  upon  a  temporary  suspension  of 
the  power  of  will,  speedily  disappear. 

It  is  far  too  common  a  practice  to  treat  this  state 
either  as  being  under  the  patient's  control,  or  as  being 
a  condition  of  no  material  moment,  inasmuch  as  it  does 
not  arise  from  permanent  organic  injury  or  disease.  It 
is  unjust,  as  well  as  irrational,  to  treat  the  condition  as 
one  of  little  moment.  It  is  true  that  we  are  apt  to 
speak  lightly  of  hysteria  in  women.  But  in  reality  even 
in  their  case  it  is  often  a  most  formidable  as  well  as 
intractable  disease.  We  only  know  it  by  its  effects.  We 
use  the  term  "  hysteria  "  to  hide  our  ignorance  of  what 
this  condition  really  consists.  To  me,  I  confess,  the 
sight  of  a  man  of  middle  age,  previously  strong  and 
healthy,  active  in  his  business  and  in  all  the  relations  of 
life,  suddenly  rendered  "  hysterical,"  not  merely  for  a 
few  hours  or  days,  by  some  sudden  and  overwhelming 
calamity  that  may  for  the  time  break  down  his  mental 
vigor,  but  continuously  so,  for  months  and  even  years, 
is  a  most  melancholy  spectacle,  and  is  a  condition  that 
certainly  to  my  mind  is  an  evidence  of  the  infliction  in 
some  way  of  a  serious,  and,  for  the  time,  disorganizing 
injury  of  the  nervous  system,  though  happily,  that 
injury  is  not  in  general  of  a  permanent  nature,or  attended 
by  organic  changes. 

This  emotional  or  hysterical  state  not  unfrequently 
occurs  as  an  independent  affection,  without  any  con- 
comitant complication,  yet  cases  every  now  and  then 
occur  in  which  there  is  real,  possibly  permanent  and 
organic  injury,  inflicted  upon  some  part  or  organ  of  the 
body,  the  symptoms  of  which  become  mixed  up  with 
and  obscured  by  those  arising  from  the  purely  emotional 
state.  This  complication  of  hysteria  and  real  injury  is 
one  that  is  extremely  difficult  to  unravel,  and  it  is  just 
this  condition  that  taxes  the  diagnostic  skill  of  the  sur- 
geon to  the  very  uttermost,  and  in  which  so  much  con- 
flict of  opinion  is  apt  to  occur  between  different  practi- 


OF  THE   SPINE.  1 79 

tioners  as  to  the  real  value  to  be  attached  to  any  given 
set  of  symptoms. 

The  diagnosis  of  hysteria  following  shock  has  to  be 
made,  i.  From  organic  disease  of  the  spine  or  elsewhere, 
and  2.  From  incipient  softening  of  the  brain. 

The  diagnosis  of  this  hysterical  state,  therefore,  and 
the  separation  of  those  phenomena  that  are  purely  ner- 
vous or  hysterical  from  those  that  are  the  result  of 
structural  lesion,  becomes  one  of -very  great  importance. 
In  making  it,  there  are  three  principal  points  to  which 
attention  should  be  directed.  The  ist  is  the  mental 
state  ;  the  2nd  is  the  character  of  the  local  nervous 
symptoms,  such  as  pain  and  paralysis ;  and  the  3rd  is 
the  condition  of  the  bodily  health. 

1.  The  mental  state  has  already  been  described,  and 
I  need  not  refer  to  its  character,  but  there  are  a  few 
points  in  connection  with  it  that  deserve  special  atten- 
tion in  its  diagnostic  aspect.  The  first  is  that  it  devel- 
ops very  speedily  after  the  accident,  possibly  at  the 
very  moment  of  the  catastrophe,  or  very  shortly  after- 
wards, at  most  in  a  few  hours  or  a  day  or  two.  In  this 
respect  it  differs  materially  from  those  mental  condi- 
tions that  go  on  slowly  and  progressively  as  a  conse- 
quence of  chronic  irritation  of  the  brain  or  its  mem- 
branes, and  which  require  a  considerable  time  for  their 
development.  Then,  secondly,  the  mental  condition, 
and  indeed  all  the  symptoms  of  this  state,  are  more  or 
less  continuous  ;  they  are  not  progressive  ;  they  are  just 
as  severe  at  the  end  of  two  or  three  days  as  after  the 
the  lapse  of  a  year  or  two.  There  may  be  fluctuations, 
but  there  is  never  a  steady  progress  in  the  symptoms. 
Then  again,  there  is  a  tendency  to  exaggerate  every- 
thing connected  with  the  patient's  own  ailments,  and  a 
disinclination,  if  not  a  complete  inability,  to  entertain 
a  hopeful  view  of  his  state ;  he  prophesies  every  possi- 
ble evil,  such  as  paralysis  and  insanity,  as  impending 
over  him. 

2.  The  pain  is  very  peculiar,  and  differs  entirely  from 
that  which  is  the  result  of  organic  disease.  It  par- 
takes of  the  general  characteristic  of  hysterical  pain, 
consisting  rather  in  diffused  cutaneons  hyperaesthesia, 


l8o  ANEMIA 

than  in  any  defined  neuralgic  affection,  such  as  arises 
from  pressure  upon  the  nerve  trunks  on  their  exit  from 
the  spinal  column  ;  and  still  less  is  there  any  of  that 
distinctly  circumscribed  or  localized  tenderness  on  pres- 
sure, confined  to  one  spot,  where  it  is  persistent  and 
greatly  increased  on  movement  of  any  kind,  which  is  so 
characteristic  of  inflammatory  pain.  It  is  unattended 
by  any  objective  phenomena.  Thus,  although  the 
patient  will  not  allow  you  to  touch,  without  the  mani- 
festation of  the  most  acute  suffering,  any  portion  of  the 
skin  of  his  back,  yet  there  is  perfect  flexibility  of  the 
spine,  perfect  power  of  moving  the  body,  and  an  utter 
absence  of  all  rigidity  of  the  muscles.  There  is  no 
objective  sign  whatever  with  which  the  pain  can  be 
connected.  Remember  that  pain  in  a  part  is  not  per  se 
and  independently  of  objective  signs  an  indication  of 
disease  of  the  part  which  is  its  seat.  Yet  although  this 
is  undoubtedly  the  case,  it  must  be  admitted  that  a 
long-continued  and  persistent  localized  pain  is  indica- 
tive of  a  morbid  state  of  the  nervous  system — either  in 
the  nerves  of  the  part  itself,  or  as  a  reflex  neuralgia 
dependent  on  central  irritation. 

3.  The  functions  of  the  various  organs  of  the  body 
are  usually  well  and  healthily  performed.  The  temper- 
ature is  normal,  the  ophthalmoscope  makes  no  revela- 
tion, and  the  pulse,  though  usually  quick  and  weak,  is 
regular.  The  rapidity  of  the  pulse  will  vary  greatly 
and  very  suddenly.  There  is  no  more  derangement  of 
bodily  health  than  would  naturally  ensue  from  the  life 
of  indolence  of  body  and  vacuity  of  mind  that  is  usu- 
ally led  by  patients  of  this  kind.  It  may  be  observed, 
in  connection  with  this  matter,  that  the  persons  who 
suffer  from  this  kind  of  emotional  or  hysterical  mani- 
festation after  comparatively  slight  injuries  will  often 
be  found  to  be  those  who  previously  had  had  their  ner- 
vous energies  exhausted  by  overwork  or  dissipation,  or 
who  had  suffered  greatly  from  anxiety  of  mind  from 
business  losses  or  worries.  It  will  also  generally  be 
found  that  they  are  individuals  of  little  intellectual 
attainm.ent  or  mental  resource ;  and  certainly  one  con- 
dition which  more  than  another  maintains  the  emo- 


OF  THE  SPINE.  iSl 

tional  state  is  the  utter  want  of  occupation  either  of 
body  or  mind  to  which  such  patients  voluntarily  resign 
themselves.  One  of  the  conditions  which  may  possibly 
be  dependent  upon  this  very  state,  but  which  certainly 
at  the  same  time  tends  to  maintain  it,  is  the  utter  ina- 
bility to  occupy  the  mind  in  a  healthy  and  active  man- 
ner. 114. 

Prognosis. — My  experience  of  these  cases  leads  me  to 
consider  the  prognosis  as  much  more  favorable   than 
might  have  been  anticipated,  or  than  I  was  at  one  time 
disposed  to  consider  it.     Patients  suffering  in  the  way 
that  I  have  been  describing,  usually  make  good  recov- 
eries in  a  comparatively  short  space  of  time.     But  never 
until  the  anxieties  of  litigation  and  the  harass  of  a  trial 
have  passed   away.     Until   this  ordeal  has  been  gone 
through,  it  is  hopeless  to  expect  an  improvement,  or 
even  a  mitigation  in  the  symptoms.     On  the  contrary, 
there  is  usually  an  aggravation  of  them  for  a  few  weeks 
previous  to  the  trial,  and  not  uncommonly  a  most  dis- 
tressingly painfnl  manifestation  of  them  in  the  court  of 
law  itself— the  plaintiff,  when  undergoing  examination 
in  the  witness-box,  commonly  breaking  down,  suddenly 
bursting  into  tears,  sobbing,  or  screaming  hysterically, 
and  having  to  be  carried  out  of  court  in  a  most  melan- 
choly state  of  utter  prostration.     These  scenes,  painful 
as  they  may  be  to  witness,  are   not,  happily,  the  pre- 
ludes to,  or  indications  of,  any  serious  aggravation  of 
the  symptoms,  but  more  commonly  than  not,  their  last 
active  development. 

But  although  experience  of  these  cases  has  now  shown 
that  the  purely  hysterical  or  emotional  state  that  results 
from  a  railway  shock  is  not  an  indication  of  permanent 
organic  or  even  serious  disease  of  the  nervous  system, 
yet  it  requires  much  care  and  no  little  experience  to 
avoid  falling  into  the  fatal  error  of  attributing  symp- 
toms that  are  in  reality  dependent  upon  organic  mis- 
chief of  the  brain  or  cord  with  those  that  are  of  this 
purely  emotional  character.  But  the  error  may  be 
avoided  by  bearing  this  in  mind,  that  no  organic  or 
permanent  injury  can  possibly  exist  without  develop- 
ing objective  signs  of  some  kind— those  objective  signs 


182  ANEMIA 

to  which  I  have  had  such  frequent  occasion  in  these 
lectures  to  refer,  and  which,  consequently,  I  need  not 
detail  here.  These  objective  signs  will  stand  out  prom- 
inently in  the  midst  of  the  variety  of  subjective  symp- 
toms which  at  once  characterize  and  constitute  this 
hysterical  state.  These  cases  also  clear  themselves  up 
in  their  progress.  What  is  obscure  at  first  becomes  evi- 
dent as  the  sun  at  noonday  after  a  time.  If,  therefore, 
you  are  in  any  doubt  as  to  their  real  nature,  wait  and 
watch. 

This  maxim  is  peculiarly  applicable  when  we  are 
called  upon  to  effect  a  diagnosis  between  hysterical 
shock  and  incipient  brain-softening.  There  is  of  course 
no  difficulty  in  determining  the  fact  of  the  hysteria  in 
all  those  cases  in  which  the  well-known  and  character- 
istic symptoms  of  this  condition  occur  in  the  young, 
especially  in  women. 

But,  when  met  with  in  the  middle-aged  or  elderly, 
and  more  particularly  in  men,  the  diagnosis  is  by  no 
means  easy.  In  such  cases  the  emotional  state  alter- 
nating with  fits  of  irritability  and  of  hypochondriasis 
closely  resembles  the  early  stages  of  cerebral  softening. 
But  the  diagnosis  may  usually  be  effected  by  attention 
to  this  point,  viz.:  whether  the  symptoms  have  devel- 
oped early  after  the  accident  and  to  their  full  extent, 
or  have  come  on  slowly  and  progressively  at  a  late 
period.  If  early  and  fully,  it  is  obvious  that  time  would 
not  have  been  sufficient  for  the  development  of  cere- 
bral softening.  If  slowly  and  progressively,  and  if 
dependent  on  this  condition,  other  and  unmistakable 
signs  of  mental  decadence  or  of  paralysis  will  soon 
show  themselves,  and  time  will  certainly  clear  up  all 
doubt  on  the  diagnosis. 

The  hypochondriasis  of  oxaluria  and  the  peculiar 
nervous  state  associated  with  that  condition  have  many 
points  of  resemblance  to  hysterical  shock  ;  and  indeed 
it  is  quite  possible  that  oxaluria  may  be  occasioned  by 
the  mental  anxiety  and  depression  consequent  on  a 
railway  injury.  In  all  cases  of  doubt  the  microscopical 
examination  of  the  urine  will  at  once  solve  the  diffi- 
culty as  to  the  diagnosis,  though  it  does  not  determine 


OF  THE   SPINE.  1 83 

whether  the  oxaluria  be  the  cause  or  the  consequence 
of  the  nervous  depression  with  which  it  is  associated. 
In  primary  oxaluria,  however,  I  am  not  aware  of  dif- 
fused hyperaesthesia  being  a  permanent  symptom  as  it 
is  in  most  cases  of  hysterical  shock. 

Unconsciousness,  insensibility,  stupor,  or  syncope 
frequently  occur  in  connection  with  concussion  of  the 
spine  and  shocks  to  the  nervous  system  in  railway  and 
other  accidents.  It  is  impossible  to  overrate  the  impor- 
tance of  the  production  of  unconsciousness  by  and 
at  the  moment  of  the  occurrence  of  the  accident.  It  is 
of  itself,  and  irrespective  of  any  other  condition,  the 
evidence  of  the  infliction  of  a  severe  shock  upon  the 
brain,  even  though  no  blow  has  been  inflicted  upon  the 
head,  and  the  violence  has  only  consisted  in  a  general 
concussion  or  jar  of  the  whole  body.  If  the  brain  be 
in  any  way  concussed  to  such  an  extent  as  to  become 
unconscious  of  surrounding  conditions  and  of  all 
external  influences,  an  immediate  or  primary  impression 
of  the  most  serious  character  must  have  been  inflicted 
upon  it,  and  any  after  or  secondary  consequence  may 
become  possible.  No  after  consequence,  indeed,  can 
possibly  be  so  serious  as  is  that  immediate  annihilation 
of  all  sense  and  consciousness  on  the  receipt  of  the 
injury,  which  is  manifested  by  the  sudden  production 
of  insensibility.  The  commotion  that  the  brain  sub- 
stance sustains  at  the  moment  that  the  patient  is  stun- 
ned may  lead  to  changes  that  may  eventually  result  in 
the  worst  possible  forms  of  organic  disease,  paralysis, 
epilepsy,  or  cerebral  softening.  But  for  the  uncon- 
sciousness to  be  of  full  and  grave  clinical  value  it  must 
be  immediate ;  it  must  be  contemporaneous  with  the 
receipt  of  the  injury ;  it  must  be  the  direct  and  instan- 
taneous effect  of  the  physical  shock  that  the  brain  has 
sustained  directly  by  a  blow  on  the  head,  or  indirectly 
by  general  concussion  of  the  body  transmitted  to  it. 
It  is  only  under  these  circumstances  that  it  is  of  the 
nature  of  true  concussion  of  the  brain,  and  that  it  is 
really  grave.  This  kind  of  unconsciousness,  which  is 
physical  in  its  cause,  and  maybe  full  of  importance  in 
its  results,  has,  I  believe,  always   this  peculiarity,   that 


1 84  ANAEMIA  OF  THE   SPINE. 

on  the  sufferer  regaining  his  consciousness  there  will  be 
found  to  be  a  loss  of  recollection  of  something  if  not 
of  all  that  is  connected  with  the  accident.  The  memory- 
will  be  perfect  up  to  one  point ;  but  then  there  will  be 
a  gap  which  the  patient  cannot  possibly  fill  up  ;  there 
may  even  be  loss  of  memory  (and  this  does  not  unfre- 
quently  occur)  of  some  of  the  circumstances  that 
immediately  preceded  the  infliction  of  the  injury. 
Thus,  for  instance,  a  driver  will  remember  his  horses 
running  away,  but  he  will  not  recollect  how  he  was 
thrown  from  the  coach-box,  an  event  which  necessarily- 
occurred,  before  he  struck  his  head  upon  the  ground, 
and  thus  was  rendered  unconscious.  This  loss  of 
memory  of  events  immediately  antecedent  to,  as  well 
as  those  actually  connected  with,  the  infliction  of  the 
injury,  is  a  very  remarkable  circumstance,  and  may  be 
taken  as  a  positive  proof  that  the  brain-substance  has 
sustained  a  severe  commotion  of  physical  lesion.  The 
chain  of  memory  is  broken  abruptly  at  some  occurrence 
often  of  a  very  trivial  character  antecedent  to  the  acci- 
dent, and  the  gap  left  can  never  be  filled  up  by  any 
mental  effort  on  the  part  of  the  patient. 

But  there  is  another  kind  of  unconsciousness  of  a 
totally  different  character :  this  is  the  emotional,  not 
physical,  form  of  insensibility.  This  form  of  uncon- 
sciousness partakes  more  of  the  character  of  syncope 
than  of  shock.  It  differs  from  the  true  physical  stun- 
ning in  this,  that  it  does  not  usually  occur  at  the 
moment  of  the  accident,  but  generally  immediately 
afterwards.  It  arises  from  shock  to  the  mind,  and  not 
from  physical  lesion  of  the  brain  structure.  It  is  the 
result  of  terror,  of  the  horror  of  the  situation,  of  the 
painful  sights  witnessed,  possibly  of  the  pain  suffered 
by  the  patient  from  the  infliction  of  some  wound.  This 
form  of  syncopal  unconsciousness  differs  from  physical 
insensibility  not  only  in  not  being  immediate,  and  in 
occurring  a  few  moments  after  the  accident,  but  especi- 
ally in  not  being  followed  by  the  obliteration  of  all 
recollection  of  the  event.  Indeed  the  concomitant  cir- 
cumstances of  the  accident  which  has  occasioned  it  are 
usually  most  strongly,  minutely,  and  indelibly  impressed 


CONCUSSION   OF  THE   SPINE.  185 

on  the  memory.  It  is  of  the  character  of  swoon  or 
faint  rather  than  of  brain  shock,  and  leaves  no  after 
consequences  of  a  serious  character. 


LECTURE  IX. 

ON  THE  COMPLICATIONS  OF  CONCUSSION  OF  THE  SPINE, 
AND  ON  THE  INFLUENCE  OF  INJURY  OF  THE  PERI- 
PHERY OF  NERVES  ON  THE  CENTRAL  PORTIONS  OF 
NERVOUS    SYSTEM. 

Independently  of  those  lesions  which  are  more  espe- 
cially referable  to  the  nervous  system  and  the  organs 
of  sense,  there  are  several  complications  which  are 
specially  apt  to  occur  in  cases  of  concussion  of  the 
spine.  These  complications  often  assume  a  very  promi- 
nent character,  and  tend  to  divert  attention  from  the 
real  and  primary  injury  of  the  nervous  system. 

These  complications  consist  of  sacrodynia,  vomiting, 
discharge  of  blood  from  the  bowels,  laceration  of  muc- 
ous membrane  of  rectum,  mucous  desquamation  from 
colon  and  rectum,  suppression,  retention,  and  incon- 
tinence of  urine,  haematuria,  diabetes,  and  phlebitic 
thrombosis.  We  shall  consider  them  briefly  and  solely 
as  complications  of  the  condition  I  am  now  describing. 
In  addition  to  them  I  shall  say  a  few  words  on  the 
effects  of  peripheral  injuries  of  nerves  on  the  nervous 
centres. 

Sacrodynia. — Severe  blows  on  the  sacral,  gluteal,  and 
lower  lumbar  regions  frequently  occasion  concussion  of 
the  spinal  cord,  and  even  of  the  brain.  Even  though 
the  symptoms  of  concussion  of  the  nervous  centres 
arise  from  more  direct  injury  of  the  spine  or  head,  yet 
in  the  accident  that  causes  them  the  sacro-lumbar 
region  may  be  violently  struck.  This  is  very  frequently 
the  case  in  railway  collisions,  where  the  sufferer  is  thrown 
forwards  and  then  bumped  backwards  against  the  hard 
seats  or  unstuffed  partitions  of  second  and  third   class 


t86  COMPLICATIONS   OF 

carriages.  The  effects  of  such  blows  or  bumps  as  these 
is  to  develop  a  class  of  symptoms  that  may  exist  inde- 
dendently  of  those  of  spinal  concussion,  or  that  may  be 
associated  with  them,  and  by  this  association  not  only 
very  materially  to  complicate  the  diagnosis  of  the  case, 
but  to  add  greatly  to  the  patient's  sufferings  and  disa- 
bilities. 

This  group  of  symptoms,  to  which  I  give  the  name 
of  Sacrodynia,  are  as  follows :  Soon,  but  not  necessarily 
immediately,  after  the  accident  the  patient  feels  a  dif- 
fused pain  over  the  whole  of  the  sacral  and  sacro-lum- 
bar  regions.  It  is  usually  most  intense  over  the  sacrum, 
and  more  especially  over  the  sacro-iliac  synchondrosis ; 
but  it  is  by  no  means  confined  to  this  part.  It  extends 
upwards  as  high  as  the  fourth  or  even  the  third  lumbar 
vertebra,  and  laterally  perhaps  to  within  an  inch  or  two 
behind  the  trochanters.  But  the  sacrum  is  the  focus  of 
greatest  intensity.  When  the  sacro-iliac  junction  also 
is  the  seat  of  suffering,  it  is  in  the  majority  of  cases 
the  left  one.  Over  the  whole  of  this  region  there  is 
tenderness  on  pressure,  and  the  pain  is  greatly  increased 
by  movements  of  all  kinds.  There  is  no  nocturnal  ex- 
acerbation. There  is  no  external  sign  of  injury,  in  the 
way  of  swelling,  heat,  or  discoloration.  The  patient 
cannot  hold  himself  erect  without  an  increase  of  the 
pain,  hence  he  has  a  tendency  to  stoop  slightly  forwards, 
aud  perhaps  to  incline  to  one  side.  Advancing  the 
lower  extremities  increases  the  pain  greatly,  the  patient 
therefore  walks  with  difficulty,  takes  short  steps,  leans 
on  a  stick,  and  when  one  side  is  more  painful  than  the 
other,  drags  the  leg  on  that  side.  As  I  have  already 
said,"  the  left  side  is  more  commonly  the  one  that  is 
most  painful,  hence  it  is  that  the  left  leg  is  so  frequently 
"  dragged  "  in  these  cases.  The  greater  frequency  and 
greater  degree  of  sacrodynia  on  the  left  side  than  on 
the  right,  and  the  consequent  drag  of  the  left  leg,  are 
very  notable  circumstances.  They  occur  in  at  least 
three-fourths  of  all  the  cases.  The  only  explanation 
that  I  can  give  of  it  is  this :  In  a  railway  collision,  when 
a  person  is  thrown  forwards  he  naturally  thrusts  out  his 
right  hand  more  than  the  left,  in  order  to  save  himself 


CONCUSSION   OF  THE   SPINE.  1 87 

an_  to  clutch  at  some  object  for  support.  In  doing  so 
he  turns  the  whole  of  the  right  side  forwards,  and  when 
thrown  back  again  on  to  the  seat  or  partition  in  the  re- 
bound of  the  carriage,  he  strikes  first,  and  with  greatest 
violence,  the  left  side  of  the  pelvis,  which  is  slightly  ro- 
tated backwards. 

The  duration  of  these  symptoms  is  very  prolonged. 
When  once  they  have  fairly  set  in,  they  will  last  for 
many  months,  often  for  a  year  or  two. 

This  condition  is  a  very  serious  one,  not  on  account 
of  any  danger  to  life  or  limb,  but  owing  to  the  pain  in 
standing  and  moving  incapacitating  the  sufferer  for  all 
active  exercise  and  exertion,  and  thus  materially  restrict- 
ing the  enjoyment  and  usefulness  of  life. 

In  its  pathology  sacrodynia  seems  to  resemble  coc- 
cydynia,  as  it  does,  indeed,  in  its  symptoms  and  dura- 
tion. The  pain  does  not  follow  the  anatomical  course 
of  any  nerve,  and  cannot  therefore  be  referred  to  the 
class  of  neuralgias.  It  appears  to  be  the  result  of  direct 
bruising  of  the  extensive  planes  of  aponeurotic  and 
fascial  structures  in  this  region,  with  sprain  of  the  vari- 
ous ligamentous  structures  there  met  with.  The  sacro- 
vertebral,  the  ilio-lumbar,  the  sacro-iliac,  and  the  great 
sacro-sciatic  ligaments  may  all  be  more  or  less  strained 
in  the  bumps,  twists,  and  wrenches  to  which  the  pelvis 
and  lower  part  of  the  spine  are  subjected  in  the  acci- 
dents under  consideration.  And  according  as  the  vio- 
lence falls  more  or  less  directly  on  one  or  other  of  these 
ligaments,  so  the  patient  will  suffer  more  or  less  in  the 
parts  where  it  is  situated.  The  long  duration  of  the 
pain  in  these  cases  of  sacrodynia  is  just  what  we  find  in 
all  cases  of  ligamentous  strain  elsewhere. 

The  diagnosis  of  sacrodynia  has  to  be  made  from 
I.  Rheumatism  ;  2.  Spinal  concussion. 

I.  From  rheumatism,  whether  it  shows  itself  in  the 
form  of  lumbago  or  sciatica,  the  diagnosis  is  easily 
made  by  attention  to  the  seat  of  the  pain,  which,  in 
lumbago,  is  above  the  ilium  and  on  either  side  of  the 
lumbar  spine  ;  in  sciatica,  along  the  course  of  the  greater 
and  upper  sciatic  nerves,  and  by  the  absence  of  noc- 
turnal exacerbations  or  of  climatic  influences  in  sacro- 


1 88  COMPLICATIONS   OF 

dynia.  The  following  method  may  be  relied  on  as  ef- 
fecting at  once  the  diagnosis  between  sacrodynia  and 
sciatica :  Place  the  patient  in  the  recumbent  position, 
fix  the  pelvis  and  extend  the  leg,  then  place  one  hand 
on  the  knee  so  as  to  prevent  its  being  bent,  and  with 
the  other  draw  up  the  foot  forcibly  so  as  to  depress  the 
heel  and  thus  put  the  sciatic  nerve  on  the  stretch.  If 
the  pain  be  due  to  sacrodynia  it  will  not  be  increased 
by  this  manoeuvre ;  if  due  to  sciatica,  it  will  be  greatly 
aggravated  when  the  nerve  is  thus  stretched  out.  The 
total  absence  of  those  constitutional  derangements 
which  are  common  in  rheumatism,  and  the  usual  co-ex- 
istence of  a  state  of  great  nervous  depression  in  sacro- 
dynia, will  tend  to  make  the  diagnosis  more  easy. 

2.  From  spinal  concussion  the  diagnosis  is  not  always 
so  easy,  and  indeed  I  have  frequently  seen  these  cases 
of  sacrodynia  mistaken  for  and  treated  as  cases  of 
spinal  concussion.  The  mistake  is  the  more  liable  to 
occur  as  the  dragging  of  the  leg  seems  paralytic,  when 
in  reality,  so  far  from  being  dependent  on  loss  of  inner- 
vation,it  is  in  reality  due  to  the  pain  that  is  occasioned 
when  any  attempt  is  made  to  move  the  leg  forwards, 
and  thus  to  put  the  injured  ligaments  on  the  stretch. 
From  the  nervous  symptoms  resulting  from  spinal  con- 
cussion the  diagnosis  may  thus  be  made  by  attending 
to  the  seat  of  the  pain  and  by  the  absence  of  all  the 
special  symptoms  that  characterize  the  nervous  lesion. 
But  it  is  very  important  to  bear  in  mind  that  in  a  very 
large  proportion  of  cases  sacrodynia  is  associated  with 
spinal  concussion,  and  that  the  symptoms  of  the  two 
.conditions  co-exist.  The  diagnosis  must  then  be  effected 
by  a  careful  examination  of  the  spine  whilst  the  patient 
is  lying  down  in  the  prone  position,  and  the  pelvis  is 
freed  so  as  to  take  off  all  weight  from  it,  and  to  prevent 
all  movement  between  it,  the  sacrum,  and  the  lumbar 
vertebrae. 

The  dragging  of  the  limb  which  gives  this  paralytic 
appearance  to  patients  suffering  from  sacrodynia  may 
be  diagnosed  from  true  paralysis  by  finding  that  w^hen 
the  patient  is  recumbent  the  movements  of  the  foot, 
the  electric  sensibility  and  irritability,  are  perfect. 


CONCUSSION   OF  THE   SPINE.  1 89 

The  diagnosis  from  coccydynia,  and  from  the  diffused 
pain  of  an  irritable  ulcer  of  the  rectum,  is  readily  made  by 
the  ordinary  examination,  digital  and  ocular,  of  the  parts. 

Nerve  Complications. — Any  affection  of  the  nerves  of 
the  face  is  necessarily  a  very  serious  complication,  as 
it  indicates  either  primary  or  secondary  mischief  of  the 
basic  meninges  or  of  the  base  of  the  brain  itself. 

The  portio  dura  of  the  seventh  nerve  is  the  trunk 
that  is  most  frequently  thus  affected.  The  motor  nerves 
supplying  the  muscles  of  the  eyeball  are  rarely  so  ;  the 
lingual  nerve  but  rarely. 

Any  loss  of  power,  however  slight,  about  the  muscles 
of  the  face,  &c.,  must  be  carefully  watched,  and  cannot 
but  be  regarded  as  a  serious  extension  of  mischief 
upwards.  Drooping  of  the  angle  of  the  mouth  or  of 
the  eyelid,  inability  to  whistle,  to  sniff,  to  knit  the 
brows,  a  deviation  of  the  tongue  to  the  sides  (not  to  be 
accounted  for  by  loss  of  teeth),  are  all  important  signs. 

In  some  cases  instead  of  paralysis  there  is  spasm  of 
the  muscles  supplied  by  the  facial  nerve.  In  this  case 
the  spinal  accessory  will  very  commonly  be  found  to  be 
similarly  affected,  and  there  will  be  twitchings  often  of 
a  very  marked  character  every  few  minutes,  not  only  of 
the  side  of  the  face,  but  of  the  muscles  supplied  by  the 
spinal  accessory,  so  that  the  head  is  jerked  downwards, 
and  to  the  sides. 

This  unilateral  clonic  spasm  of  these  nerves  is  not 
unfrequently  the  precursor  of  epilepsy  or  of  hemiplegia. 

I  have  seen  cases  of  concussion  of  the  spine  with  no 
external  sign  of  injury,  and  few,  if  any,  serious  symp- 
toms in  the  early  stages,  gradually  go  on  through  a  long 
series  of  progressive  developments,  extending  through 
many  months,  to  clonic  spasm  of  the  muscles  supplied 
by  the  facial  and  spinal  accessory  nerves,  spasm  of  a 
clonic  character  excited  by  touching  the  skin  of  the  face, 
brushing  the  hair  on  the  affected  side  of  the  head, 
pressing  upon  a  tender  spot  in  the  cervical  spine,  exer- 
cising pressure  with  the  finger  over  the  sub-occipital  or 
supra-scapular  nerves,  and  terminate  at  last  in  creeping 
paralysis  of  the  leg,  short  but  frequently  recurring  epi- 
leptiform seizures  and  hemiplegia. 


IQO  COMPLICATIONS   OF 

The  fifth  pair  of  nerves  as  a  whole,  or  in  any  of  their 
branches,  appears  to  be  remarkably  free  from  paralytic 
affections.  I  have  never  seen  anaesthesia  of  the  face  as 
a  consequence  of  general  nervous  shock,  or  as  a  sequence 
and  complication  of  spinal  concussion.  The  only  con- 
dition approaching  to  paralysis  of  any  branch  of  the 
fifth  that  I  have  had  occasion  to  observe  has  been  numb- 
ness of  the  teeth  on  one  side,  sometimes  in  the  upper,  at 
others  in  the  lower  jaw.  But  in  these  cases  there  has 
always  been  a  direct  blow  on  the  face,  and  the  numbness 
was  primary  and  immediate,  though  in  some  cases  very 
persistent.     Hyperaesthesia  of  the  fifth  is  equally  rare. 

Syphilis. — The  question  may  arise  as  to  how  far  the 
symptom  may  arise  from  syphilitic  disease  of  the  brain 
or  cord  or  their  meninges  rather  than  from  concussion 
of  the  nervous  centres.  I  have  seen  several  instances 
of  this  not  only  after  railway  collisions,  but  in  accidents 
in  a  gymnasium,  by  the  overturning  of  a  carriage,  &c. 

When  the  patient  is  actually  suffering  from  the  more 
advanced  forms  of  constitutional  syphilis,  the  difficulty 
in  the  diagnosis,  and  in  the  degree  of  relation  that  the 
symptoms  bear  to  syphilis,  or  to  injury,  may  be  very 
great.  The  error  must  not  be  committed  of  looking  at 
the  paralysis  as  necessarily  the  result  of  syphilitic  dis- 
ease of  the  cord  or  its  membranes  merely  because  it 
co-exists  with  manifestations  of  constitutional  syphilis. 
The  paralysis  of  a  syphilitic  patient  may  be  traumatic, 
and  not  in  any  way  connected  with  or  dependent  on 
the  specific  taint  in  the  system.  Careful  attention  to 
the  history  of  the  case  and  the  mode  of  progression  of 
the  symptoms  may  do  much  to  unravel  the  tangle  of 
this  complication ;  but  there  are  two  or  three  points 
that  deserve  special  consideration.  Thus  the  ptosis, 
strabismus,  and  double  vision  which  are  so  common  in 
the  syphilitic  forms  of  brain  disease  are  very  rare  after 
spinal  concussion.  Thus,  also,  the  comparatively  early 
occurrence  of  epileptiform  or  comatose  symptoms  in 
the  specific  constitutional  disease  should  be  noted.  In 
concussion  of  the  spine  also  there  will  be  spinal  tender- 
ness and  pain  in  movement  of  a  marked  character,  which 
does  not  occur  in  syphilitic  disease, 


CONCUSSION  OF  THE  SPINE.  I9I 

The  following  case  will  illustrate  some  of  these 
points: — 

Case  43. — Fall  in  Gymnasium — Blow  on  Back — Slow 
Development  of  Spinal  Symptoms — Constitutional  Syphi- 
lis—  Were  Symptoms  due  to  Injury  or  Syphilis  ? — An 
officer,  aged  27,  fell  whilst  ''  playing  tricks  "  with  a  com- 
panion in  a  gymnasium,  and  was  struck  in  the  middle 
of  the  back.  He  suffered  a  good  deal  at  the  time,  was 
laid  up  for  a  week,  and  gradually  got  about  so  as  to  be 
as  active  as  before.  He  contracted  syphilis,  and  had 
secondary  symptoms.  Two  years  and  a  half  after  the 
accident  he  began  to  drag  the  right  leg,  which  became 
wasted,  was  cold  and  numb ;  his  sight  became  affected ; 
there  was  external  strabismus  of  the  left  eye  and  dou- 
ble vision ;  he  had  some  scaly  syphilides  occasionally 
appearing  on  the  body ;  the  right  leg  was  found  on 
measurement  to  be  rather  more  than  half  an  inch 
smaller  than  the  left ;  there  was  no  spinal  pain  or  ten- 
derness on  pressure  of  any  part  of  the  vertebral  column. 
Were  these  symptoms  referable  to  the  accident  or  to 
the  constitutional  syphilis?  The  history  of  the  case, 
the  lengthened  interval  between  the  fall  and  the  para- 
lytic symptoms,  the  existence  of  secondaries,  the 
absence  of  all  signs  of  spinal  irritation,  and  the  strabis- 
mus, all  pointed  to  syphilis  as  their  cause.  He  was 
treated  with  large  doses  of  iodide  of  potassium,  iron, 
and  with  galvanism,  and  made  a  good  recovery. 

Extreme  cardiac  debility  is  a  very  frequent  compli- 
cation of  spinal  concussion.  The  heart's  action  is 
extremely  feeble,  the  sounds  faint  and  distant,  the  pulse 
weak  and  compressible,  and  the  patient  liable  to  attacks 
of  cardiac  syncope.  This  condition  often  lasts  many 
months,  and  may  possibly  become  permanent.  It  is  a 
question  for  investigation  whether  it  results  from  direct 
shock  to  the  heart  through  the  cardiac  nerves,  or 
whether  it  is  occasioned  more  indirectly  by  the  injury 
that  may  possibly  have  been  sustained  by  the  sympa- 
thetic. I  have  more  than  once  observed  great  differ- 
ence in  the  size  of  the  pulse  in  the  two  wrists  as  a 
secondary  effect  of  spinal  concussion,  and  probably  of 
implication  of  the  sympathetic. 


192  COMPLICATIONS   OF 

The  next  complication  to  which  I  wish  to  direct 
attention  is  vomiting.  Now  vomiting  in  such  cases 
may  be  of  two  kinds :  there  is  the  ordinary  vomiting 
that  occurs  on  recovery  from  concussion  of  the  brain 
from  any  cause,  and  which  tends  so  materially  by 
driving  the  blood  to  the  head  to  restore  consciousness. 
But  there  is  another  kind  of  vomiting  which  is  apt  to 
occur  in  a  more  continuous  manner  as  a  consequence  of 
concussion  of  the  upper  part  of  tne  cervical  spine.  The 
characteristics  of  this  vomiting  are,  that  it  continues 
for  weeks  or  months,  that  the  contents  of  the  stomach 
are  ejected  without  force  or  strain,  that  they  consist 
chiefly  of  masticated  food  that  has  undergone  but  little 
change,  and  that  in  consequence  of  the  persistence  of 
this  condition  the  patient's  health  and  strength  become 
greatly  wasted.  The  following  case  will  illustrate  this 
point : 

Case  44. — Blozv  on  Cervical  Spine  —  Long  continued 
Vomiting — Partial  Paralysis. — G.  D.,  a  man  about  27 
years  of  age,  met  with  an  accident  in  a  railway  collision, 
in  the  early  part  of  April,  1867,  in  which  he  was  prob- 
ably struck  across  the  nape  of  the  neck.  For  ten  days 
he  was  confined  to  his  bed,  suffering  severely  from  pain 
in  the  upper  part  of  the  neck.  Mr.  Gisborne,  of  Derby, 
who  saw  him,  states  that  at  this  time  he  was  pallid, 
looked  anxious,  complained  of  pain  in  the  back  of  the 
head ;  was  restless  at  night,  and  had  constant  sickness 
after  taking  food,  whether  fluid  or  solid.  His  pulse  was 
slow,  his  breathing  oppressed  from  a  sense  of  suffoca- 
tion, accompanied  by  very  uncomfortable  sensations 
about  his  heart.  The  patient  made  little  improvement, 
and  was  brought  up  to  London,  where  I  saw  him  on 
May  13.  I  found  him  looking,  thin,  pale,  and  anxious. 
He  stated  that  he  had  not  had  a  day's  health  or  free- 
dom from  pain  and  distress  since  the  time  of  the  acci- 
dent. He  complained  chiefly  of  pain  in  the  back  of 
the  head.  This  pain  was  increased  by  moving  the  head 
to  and  fro,  by  rotating  it,  and  by  pressing  it  down  on 
the  spine.  It  occurred  at  the  moment  of  the  accident, 
when  he  felt  a  shock  as  if  he  had  received  a  blow  from 
a  sledge-hammer,  which  was  immediately  followed  by 


CONCUSSION   OF   THE   SPINE.  I93 

a  severe  pain  shooting  down  to  the  region  of  the  heart, 
and  by  an  attack  of  vomiting.  Mr.  Evans,  of  Derby, 
under  whose  care  the  patient  had  been,  confirmed  the 
account  he  gave  of  himself.  Vomiting  had  continued 
daily  ever  since  the  accident,  in  fact  he  vomited  several 
times  in  the  course  of  each  day,  and  had  done  so  up  to 
the  time  of  my  seeing  him.  The  breathing  had  also 
been  affected,  being  shallow,  panting,  and  oppressed. 
When  he  received  the  blow,  he  had  a  sense  of  suffoca- 
tion, and  great  oppression  about  the  region  of  the  heart. 
I  saw  G.  D.  again  on  November  5.  I  found  him  worse 
in  certain  material  respects.  The  vomiting  continued, 
and  he  complained  much  of  pain  in  the  back  of  the 
head ;  but  in  addition  to  this  he  had  partial  paralysis  of 
the  right  arm  and  leg.  The  arm  was  numb,  with  a  feel- 
ing of  tingling  throughout  it,  but  more  particularly 
along  the  course  of  the  ulnar  nerve.  The  fingers  were 
contracted,  he  had  a  difficulty  in  opening  them,  and  the 
grasp  of  the  hand  was  extremely  weak.  The  right  leg 
was  weak,  numb,  and  cold.  On  measuring  it,  I  found 
that  in  the  middle  of  the  thigh  it  was  one  inch  less  in 
circumference  than  the  left  one  on  a  corresponding  line, 
and  that  the  right  calf  was  five-eighths  of  an  inch  smaller 
than  the  left,  showing  clearly  that  the  nutrition  of  the 
limb  had  been  affected.  On  enquiring  into  the  par- 
ticulars of  these  new  symptoms,  I  learned  from  Mr. 
Evans  that  the  patient  had  had  a  ''fit"  on  June  16, 
and  that  on  his  recovery  from  a  state  of  unconscious- 
ness the  symptoms  of  paralysis  had  manifested  them- 
selves. 

On  December  6,  I  again  saw  G.  D.,  in  consultation 
with  Dr.  Reynolds.  At  this  time  we  found  that  there 
were  twitchings  in  the  muscles  of  the  right  limbs,  that 
the  loss  of  power  in  them  had  been  progressive,  and 
that  although  the  vomiting  had  been  less  frequent,  the 
paralytic  symptoms  had  appeared  to  increase.  The  pa- 
tient was  thinner,  more  haggard  and  worn  in  appearance 
than  at  his  last  visit.  It  is  important  to  note  that  I  had 
frequent  opportunities  of  observing  the  vomited  mat- 
ters ;  they  were  perfectly  sweet  in  odor ;  there  was  no 
bile  or  acid,  or  glairy  mucus  about  them,  no  appearance, 
13 


194  COMPLICATIONS   OF 

in  fact,  of  disease.  They  seemed  to  consist  simply  of 
partially  digested  food.  It  would  appear  fram  the  sym- 
ptoms of  vomiting,  suffocation,  and  oppression  about  the 
chest,  that  the  patient  had  received  an  injury  somewhere 
about  the  origin  of  the  pneumo-gastric  nerve  in  the 
course  of  the  respiratory  tract,  and  indeed,  the  pain  that 
he  suffered  at  the  back  of  the  head  would  indicate  that 
this  was  the  seat  of  his  disease.  He  was  put  under  treat- 
ment consisting  of  rest,  active  counter-irritation  by 
repeated  blistering,  and  small  doses  of  calomel.  The 
case  came  to  trial,  and  so  far  as  all  compensation  claims 
were  concerned,  they  were  favorably  adjusted,  and  the 
patient  improved,  but  very  slowly.  On  January  19, 
1 87 1,  nearly  four  years  after  the  injury.  Dr.  Evans  wrote 
to  me  that  G.  D.  still  suffered  from  pain  at  the  back  of 
the  head,  aggravated  at  times.  When  very  bad,  he 
became  sick  and  vomited  as  before,  but  these  attacks 
were  less  frequent  than  they  used  to  be.  The  paralytic 
affection  of  the  right  leg  and  arm  had  improved ;  he 
could  now  use  these  limbs  more  freely,  and  could  bear  a 
moderate  amount  of  exercise.  There  was  also  a  decided 
improvement  in  the  muscular  development  in  the  limbs, 
and  the  measurement  of  the  two  legs  was  equal ;  but  he 
suffered  from  want  of  sleep,  and  was  at  times  much 
depressed  in  spirits.  Although  his  improvement  had 
been  considerable,  it  is  evident  that  at  this  period  it  was 
far  from  complete. 

Another  symptom  closely  allied  to  vomiting  is  Hic- 
cough, which,  though  less  serious,  is  often  very  distress- 
ing and  painful. 

hitestinal  Complications. — In  consequence  of  the  strain 
to  which  the  body  is  subjected,  considerable  intestinal 
disturbance  not  unfrequently  takes  place,  and  occasion- 
ally this  will  be  followed  by  copious  evacuations  of  blood 
perannum^  continuing  through  a  period  of  many  months. 
In  one  case  which  I  attended  with  Mr.  R.  Dunn,  these 
bloody  stools  continued  for  nearly  a  twelvemonth.  They 
are  altogether  unconnected  with  haemorrhoids,  and 
usually  consist  of  dark,  semi-coagulated  blood.  The 
evacuation  is  accompanied  by  a  good  deal  of  faintness. 

In  other  cases  again,  one  of  the  most  marked  symp- 


CONCUSSION   OF   THE   SriNE.  I95 

toms  consist  of  a  copious  discharge  of  intestinal  mucus 
in  large  shreds  and  flakes,  and  in  very  considerable  quan- 
tity. It  would  appear  as  if  the  shock  had  in  some  way 
damaged,  possibly  lacerated  or  inflamed,  the  mucous 
membrane  of  the  colon.  This  condition  was  very 
strongly  marked  in  the  following  case  : 

Case  45. — Shock  from  Fall — Laceration  of  Mucous 
Membrane  of  Rectum — Colitis — Epithelial  Desquama- 
tion.— Miss  W.  was  injured  in  February,  1868,  by  falling 
heavily  upon  the  ground  in  consequence  of  putting  her 
foot  into  a  hole  in  a  door-mat  in  the  waiting-room  of 
the  railway  station  at  Spalding.'^  She  was  a  woman  of 
active  habits,  a  dancing-mistress  by  profession.  She 
was  seen  by  Sir  Cordy  Burrows  and  Dr.  Taaffe,  of 
Brighton,  who  referred  her  to  me.  At  the  time  of  our 
examination  we  found  that  she  was  suffering  from  a 
concussion  of  the  spine,  and  a  shock  to  her  general 
nervous  system,  and  that  she  had  in  addition  some 
injury  to  the  lower  bowel.  This  proved,  on  examina- 
tion, to  be  a  longitudinal  fissure  of  the  mucous 
membrane  at  the  posterior  part  of  the  anus  and 
lower  part  of  the  rectum.  She  had  suffered  since 
the  time  of  the  accident  from  constant  pain  in  the 
back,  confusion  of  thought,  numbness  in  her  limbs,  and 
a  feeling  as  if  cold  water  were  running  down  her  back  ; 
a  sensation  of  being  grasped  on  both  sides  of  the  pel- 
vis ;  a  sense  of  constriction  as  if  by  a  tightened   cord 


*  This  case  involved  an  important  legal  point  which  has  a  direct  bear- 
ing upon,  and  shows  the  responsibility  entailed  by  persons  engaged  in 
business  or  profession.  It  amounts  to  this,  that  a  person  who  opens  his 
house  for  the  purpose  of  gain  renders  himself  liable  for  any  injury  sus- 
tained by  one  of  his  clients,  patients  or  customers,  on  entering  or  leaving 
that  house,  that  is  occasioned  by  the  negligence  of  himself  or  his  servants. 
But  he  is  not  liable  in  the  case  of  any  individual  coming  to  the  house  as 
a  mere  visitor.  Thus,  as  was  slated  in  this  case  by  Mr.  (now  Lord) 
Coleridge,  if  a  patient  or  client  in  going  to  the  house  of  a  medical  man 
or  solicitor  to  consult  him  professionally,  tripped  in  a  hole  in  the  carpet, 
or  fell  over  a  loose  stair  rod  and  injured  himself,  his  professional  adviser 
whose  counsel  he  was  about  to  seek  and  pay  for  would  be  liable  for  the 
injury  sustained.  But  if  the  person  came  as  a  friend  or  simple  visitor, 
and  the  house  was  opened  not  for  the  purpose  of  gain,  the  occupant 
would  not  be  liable.  The  case  of  Miss  W.  was  tried  at  Guildhall  on 
June  28,  1869,  and  a  verdict  for  large  damages  was  taken  by  consent. 


igS  COiMPLICATIONS   OF 

round  her  abdomen,  and  also  round  the  chest,  just 
below  the  breasts.  She  suffered  great  pain  in  the  abdo- 
men when  the  bowels  were  moved,  and  about  June  4 
she  noticed  that  she  was  passing  shreds  with  the  faeces, 
which  on  microscopical  examination  proved  to  be  por- 
tions of  the  epithelium  of  the  lower  bowel.  She  had 
since  almost  daily  continued  to  pass  these  shreds,  with, 
at  times,  some  muco-purulent  discharge.  I  saw  her 
again  about  this  time,  and  found  that  she  was  suffering 
from  ulceration  of  the  mucous  membrane  of  the  rec- 
tum, in  which  there  was  a  fissure.  I  advised  the  usual 
operation  of  partial  division  of  the  sphincter,  which 
was  done,  with  considerable  relief,  which  continued  for 
about  three  weeks,  when  the  symptoms  returned,  the 
portion  of  the  mucous  membrane  inside  the  anus 
appearing  healed,  but  the  upper  portion  of  the  lower 
bowel  was  very  much  irritated.  This  patient  contin- 
ued to  pass  enormous  quantities  of  large  flakes  of 
shreddy  epithelium  mixed  with  mucus.  This  continued 
for  a  great  length  of  time.  On  November  13,  1869,  a 
year  and  three-quarters  after  the  accident,  I  found  that 
this  epithelium  was  still  being  discharged  though  in  les- 
sened quantity.  Miss  W.  was  very  nervous  and  weak, 
scarcely  able  to  walk  ;  in  going  down  stairs  had  to  do 
so  backwards,  and  was  quite  unfit  for  her  profession, 
which,  indeed,  she  was  obliged  to  relinquish.  From  this 
time  she  slowly  improved,  and  eventually  recovered, 
but  for  a  long  time  continued  to  suffer  from  sacrodynia 
and  epithelial  discharge.  Since  this  occurred,  I  have 
seen  several  others  in  which  laceration  of  the  rectal 
mucous  membrane  resulted  from  falls  or  blows  in  the 
sacral  region. 

The  three  following  cases  illustrate  various  complica- 
tions of  shock  in  the  nervous  system  in  ordinary  acci- 
dents and  in  railway  collisions,  in  derangements  of  the 
thoracic  and  abdominal  organs. 

Case  46. — Fall  on  Ice.- — Hceinaturia  and  Hcemorrhage 

from  the  Bowels^  with   Contractions  of  the  Flexors  of 

the  Legs,  folloiving  Falls  on  the  Back. — A  lady  was  sent 

to  consult  me  by  Dr.  Graves,  of  Gloucester,  on  July  23, 

1872,  and  gave  the  following  history:  She  was  unmarried, 


CONCUSSTOK  OF  THE   SPINE.  I97 

and  aged  57-  Twenty  years  ago  she  fell  on  her  back 
on  the  ice  and  was  severely  shaken.  The  same  evening 
she  had  haematuria.  This  was  soon  arrested  by  treat- 
ment, but  had  recurred  occasionally.  A  few  months 
after  this  she  slipped  in  going  down  stairs,  and  struck 
her  spine  against  some  of  the  steps.  The  accident  was 
followed  by  severe  pain  and  loss  of  power  in  her  limbs, 
and  eventually  by  contraction  of  the  flexors  of  the  feet, 
so  that  her  heel  was  raised  an  inch  from  the  ground. 
Subsequently  haemorrhage  from  the  bowels  took  place, 
which  had  continued  from  time  to  time.  The  blood 
was  usually  bright,  but  sometimes  dark-colored.  She 
had  no  piles  or  obvious  cause  for  the  bleeding. 

Case  47. — Shock  to  Nervous  System  in  Raikvay  Colli- 
sion—  Various  Complications  connected  ivith  the  Thor- 
acic and  Abdominal  Organs. — Mrs.  T.  aged  28,  a  healthy 
strong  woman,  was  in  a  railway  collision  on  November 
12,  1869.  She  was  jerked  off  her  seat,  fell  to  the  bot- 
tom of  the  carriage,  where  she  was  bumped  backwards 
and  forwards  against  the  edges  of  the  seats.  She 
became  insensible,  and  was  a  good  deal  bruised  across 
the  loins.  I  saw  her  in  consultation  with  Dr.  Sedgwick, 
on  November  26,  a  fortnight  after  the  accident.  She 
was  then  in  an  extremely  prostrate  state.  On  examining 
the  back,  there  seemed  to  be  some  slight  prominence  of 
the  third  lumbar  vertebrae,  and  a  twist  of  its  spinous 
process  to  the  right  side.  She  had  vomited  repeatedly 
for  twenty-four  hours  after  the  accident,  then  several 
times  daily  during  the  following  week,  and  latterly  only 
occasionally.  The  vomiting  was  altogether  independ- 
ent of  the  food  that  she  took.  The  abdomen  was  very 
sensitive  to  the  touch.  She  suffered  great  pain,  referred 
to  the  upper  part  of  the  rectum  in  defaecation,  and  for 
eight  days  after  the  accident  she  passed  great  quantities 
of  blood  per  amun.  She  suffered  greatly  from  palpi- 
tation of  the  heart,  nervous  agitation,  frequent  inter- 
ruptions of  sleep,  and  frightful  dreams.  Her  sight  had 
become  weakened,  so  that  she  was  unable  to  read. 
There  was  a  remarkable  difference  in  the  pulse  at  the 
two  wrists,  that  in  the  left  radial  was  so  small  and  indis- 
tinct that  it  was  impossible  to  count  the  beats  ;  that  on 


198  COMPLICATIONS   OF 

the  right  was  moderately  full  and  strong,  88  in  the  min- 
ute. This  continued  for  several  days,  but  gradually 
the  pulsation  in  the  left  radial  had  become  fuller  and 
nearly  equal  in  volume  to  that  in  the  right.  She 
remained  in  bed  for  nine  days,  when  the  railway  sur- 
geon who  saw  her  advised  her  to  get  up  and  move 
about.  She  attempted  to  do  so,  but  suffered  exces- 
sive pain  in  the  back,  extending  up  to  the  head,  and 
found  she  was  quite  unable  even  to  stand,  the  attempt 
making  her  much  worse  for  several  days.  When  I  saw 
her  on  the  26th,  the  condition  above  described  gener- 
ally continued.  The  spine  was  excessively  tender  with 
violent  pain  on  movement  of  any  kind,  more  especially 
on  pressure  and  rotation.  When  the  pelvis  was  fixed 
and  the  body  rotated,  the  pain  was  very  intense.  The 
urine  was  healthy  in  character ;  there  was  no  irritabil- 
ity of  the  bladder.  The  treatment  prescribed  was  rest, 
hot  fomentations  to  the  back,  small  doses  of  perchlor- 
ide  of  mercury  and  bark ;  under  which  plan  she  gradu- 
ally mended.  The  points  of  interest  in  this  case  were 
the  continuance  of  vomiting  for  several  days,  the  pas- 
sage of  blood  pel'  anuni,  severe  palpitations  of  the 
heart,  the  difference  in  the  pulse  in  the  two  wrists, 
which  gradually  disappeared,  the  twisting  of  the  spinous 
process  of  one  of  the  lumbar  vertebrae,  and  the  gen- 
eral shock  to  the  nervous  system  as  indicated  by  the 
nervous  agitation,  the  failure  of  sight,  insomnia,  &c. 

Case  48. — Severe  Shock  in  Railway  Collision — Blow 
on  Right  Side — Long-continued  Vomiting — Gradual 
Development  of  Paraplegia^  with  Rigidity  and  Signs  of 
Spinal  Meningitis. — W.  B.  was  in  a  railway  collision  on 
November  6,  1867.  I  saw  him  for  the  first  time  on 
March  28,  1868,  He  gave  the  following  history :  At 
the  time  of  the  accident  he  was  struck  on  the  right 
hypochondrium  and  across  the  loin  on  that  side;  he 
was  severely  shaken  but  not  rendered  unconscious  ;  he 
was  able  to  walk  some  little  distance  ;  he  got  on  to  the 
step  of  an  omnibus  and  drove  home.  About  half  an 
hour  after  the  accident  he  vomited  a  quantity  of  blood. 
He  gradually  lost  power  in  the  lower  extremities,  and 
when  I  saw  him,  presented  the  following  symptoms ; 


CONCUSSION   OF   THE   SPINE.  1 99 

There  was  no  pain  on  pressure  on  any  part  of  the  spine, 
but  considerable  tenderness  over  the  sacrum.  The 
vomiting  with  which  he  had  been  seized  immediately 
after  the  accident  continued  daily  for  about  two 
months,  and  then  ceased.  There  were  slight  paralytic 
symptoms  about  the  face,  some  dropping  of  the  mouth 
on  the  right  side,  a  slight  twist  of  the  tongue,  and  dila- 
tation of  the  left  pupil.  His  mental  condition  was 
very  emotional,  approaching  to  the  hysterical  state. 
He  had  lost  from  two  to  three  stones  in  weight  in  the 
course  of  four  months.  There  was  incontinence  of 
faeces,  and  partial  loss  of  control  over  the  bladder. 
The  abdominal  muscles  were  extremely  rigid,  hard,  and 
tense ;  the  lower  limbs  were  quite  powerless.  The 
muscles  of  the  thighs  and  legs  were  rigid,  so  that  the 
knees  and  ankles  could  only  be  bent  with  dif^culty,  and 
any  attempt  at  movement  caused  extreme  pain.  There 
was  no  sign  of  palsy  or  of  muscular  relaxation,  but  the 
limbs  lay  stretched  out  in  a  rigid  manner  like  those  of 
a  corpse.  On  making  an  attempt  to  bend  the  joints 
the  whole  limb  was  lifted  up.  There  was  almost  com- 
plete loss  of  sensation  below  the  knees.  The  skin 
could  be  pricked,  pinched,  and  the  cuticular  hairs 
pulled,  without  any  feeling.  No  reflex  action  was 
excited  on  tickling  the  soles  of  the  feet.  There  had 
been  no  cramps  or  convulsive  movements  of  the  limbs. 
There  can  be  little  doubt  that  this  condition,  which 
slowly  supervened  after  the  accident,  was  dependent 
upon  spinal  meningeal  inflammation. 

The  urinary  organs  frequently  suffer  from  the  con- 
cussion to  which  the  spine  and  pelvis  are  subjected. 
In  some  cases  there  occurs  a  combination  of  retention 
and  partial  suppression  of  urine  which  is  very  remark- 
able and  peculiar  to  this  class  of  injuries. 

Case  49. — Blow  on  Upper  Part  of  the  Cervical  Spine 
— Retention  of  Urine  for  Three  Days. — In  a  man  about 
fifty  years  of  age,  who  had  received  a  severe  blow  in  a 
railway  collision  on  the  upper  part  of  the  cervical  spine, 
whom  I  saw  in  consultation  with  Mr.  Heath,  in  June, 
1874,  there  had  been  retention  of  urine  for  nearly  three 
days  after  the  accident,  but  without  any  great  disten- 


200  COMPLICATIONS   OF 

sion  of  the  bladder.  It  then  began  to  dribble  away,  and 
the  organ  emptied  itself  without  the  need  of  the  catheter. 

In  another  case  which  I  saw  some  years  ago  with 
Dr.  Bonny,  the  retention  of  urine  had  lasted  for  forty 
hours,  and  in  another  case  no  urine  had  been  passed 
till  the  third  day,  by  a  young  man  of  twenty-two.  In 
none  of  these  cases  does  the  bladder  appear  to  have 
become  over-distended.  It  would  therefore  seem  that 
there  had  been  suppression  or  arrest  of  secretion  to 
some  extent,  as  well  as  retention.  It  is  possible  that 
there  is  suppression  for  a  time — that  the  kidneys  do 
not  secrete  for  many  hours  after  having  been  concussed. 
As  they  recover  from  the  efTects  of  the  shock  they 
slowly  begin  to  secrete  again,  and  then  the  bladder, 
which  has  been  temporarily  paralyzed — stunned,  as  it 
were — fills  up  to  a  certain  point,  and  incontinence  of 
urine  sets  in,  with  partial  retention.  Throughout  the 
course  of  these  cases  of  nervous  shock  or  of  spinal  con- 
cussion, there  may  be  every  degree  of  retention  or  in- 
continence of  urine,  singly  or  combined,  dependent 
upon  more  or  less  paralysis  of  sensation  or  of  motion, 
or  both  combined. 

Hcematiiria  will  occasionally  occur,  and  in  those 
cases  in  which  I  have  seen  it  the  bleeding  has  always 
been  venous.  When  this  symptom  is  met  with  it  will 
be  associated  with  diminished  secretion  of  urine. 

Diabetes  I  have  never  seen  occur  as  a  consequence  of 
any  of  these  injuries  of  the  spine,  but  have  several 
times  met  with  it  as  a  consequence,  sometimes  tempo- 
rary, at  other  times  enduring,  of  injury  to  the  posterior 
part  of  the  brain.  I  have,  however,  seen  spinal  con- 
cussion in  previously  diabetic  subjects.  In  these  cases 
the  injury  to  the  nervous  system  very  seriously  aggra- 
vates the  diabetic  symptoms,  increases  the  quantity  of 
sugar,  and  materially  hastens  a  fatal  result. 

Phlebitis. — Among  the  distant  complications  of  spinal 
injury  it  is  necessary  to  include  embolism  and  throm- 
bosis of  the  larger  veins.  I  have  seen  this  happen  in 
several  cases,  and  I  would  especially  refer  to  Cases  22 
and  37,  in  which  this  occurrence  will  be  found  described 
as  one   of  the  more  remote  symptoms.     This  plugging 


CONCUSSTOX   OF   THE   SPINE.  201 

of  the  veins,  phlebitis,  if  you  choose  to  call  it  so,  com- 
monly occurs  in  the  lower  extremities,  and  I  imagine 
that  it  must  be  looked  upon  as  a  consequence  of  the 
absorption  of  blood  that  has  been  extravasated  into  the 
spinal  canal.  In  both  the  cases  to  which  I  refer  that 
would  appear  to  have  been  the  nature  of  the  lesion  that 
occasioned  the  paraplegia.  These  cases  of  phlebitic 
embolism,  consequent  upon  spinal  concussion  and  intra- 
spinal haemorrhage,  resemble,  therefore,  in  their  cause, 
very  closely,  similar  conditions  of  veins  that  are  not 
unfrequently  met  with  consequent  on  the  absorption 
of  disintegrating  masses  of  blood  coagulum,  and  extra- 
vasations into  the  general  areolar  tissue.  In  one  of  the 
cases  referred  to  the  patient  nearly  lost  his  life  from 
acute  inflammatory  congestion  of  the  lungs,  with  effu- 
sion into  the  pleura,  undoubtedly  due  to  embolism  of 
the  pulmonary  vessels. 

The  complication  of  pregnancy  with  spinal  concus- 
sion is  always  a  serious  one,  not  so  much  in  regard  to 
the  duration  of  the  pregnancy  as  to  the  prospect  of  re- 
covery from  the  injury  to  the  nervous  system.  Preg- 
nant women  who  suffer  from  spinal  concussion  do  not 
appear  to  me  to  have  any  special  tendency  to  miscarry, 
but  they  are  peculiarly  slow  in  recovering  from  the 
symptoms  of  nervous  shock  or  paralysis,  after  the  con- 
finement is  over.  Not  only  do  these  symptoms  con- 
tinue during  pregnancy,  but  there  is  usually  little  pros- 
pect of  amelioration  for  some  months  after  parturition, 
more  especially  if  lactation  be  permitted,  which  tends 
still  further  to  retard  recovery. 

We  will  now  proceed  to  discuss  a  subject  of  great 
importance,  and  one  that  has  not  as  yet  received  the 
attention  it  deserves,  viz.,  the  influence  exercised  by 
injury  of  the  periphery  of  a  nerve  in  exciting  slowly, 
but  progressively,  disease  in  the  nervous  centres. 

It  has  long  been  known  to  surgeons  that  incisions 
or  punctures  of  nerves  are  often  followed  by  reflex 
phenomena  of  a  serious  and  painful  character.  And  it 
is  remarkable  that  these  phenomena  are  chiefly  met 
with  when  the  cutaneous  filaments  of  the  nerves  of 
the  upper  extremity  are  the  seat  of  lesion.     In   fact, 


202  COMPLICATIONS   OF 

it  is  rather  when  the  peripheral  terminations  than 
when  the  nerve-trunks  are  wounded  that  they  manifest 
themselves.  And  in  some  cases  they  would  appear  to 
have  led  to  symptoms  which  were  clearly  indicative  of 
central  nervous  irritation.  Wounds  of  this  description 
were  more  common  formerly  than  now,  for  they  often 
occurred  during  the  ordinary  operation  of  venesection. 
And  without  going  so  far  back  as  the  account  given  by 
Ambrose  Pare,  of  the  painful  contraction  of  the  mus- 
cles of  the  arm  with  which  Charles  IX  of  France  was 
affected  for  three  months  after  an  accident  of  this  de- 
scription, I  would  refer  you  to  the  works  of  Joseph 
Swan  for  several  cases  in  illustration  of  it.  In  one 
case  especially,  the  patient,  a  woman,  who  had  been 
bled  in  the  median  vein,  suffered  severe  pain  afterwards 
up  to  the  shoulder  for  two  days,  and  was  seized  with 
violent  convulsions,  which  suddenly  ceased  on  Mr.  Swan 
making  a  transverse  incision,  about  an  inch  in  length, 
above  the  opening  in  the  vein,  so  as  to  divide  the 
wounded  cutaneous  nerve.  I  have  seen  more  than 
once,  in  cases  of  dislocation  of  the  fingers  or  of  fracture 
of  the  phalanges,  patients  suffer  much  from  cramps  and 
contractions  of  the  muscles  of  the  forearm  and  arm 
almost  of  a  tetanic  character. 

The  digital  nerves,  indeed,  are  those  the  injury  of 
of  which  is  especially  apt  to  be  followed  by  painful  reflex 
contractions  of  the  muscles  of  the  arms,  and  in  some 
cases  by  more  serious  after-consequences  indicative  of 
lesion  of  the  nervous  centres.  Messrs  Banks  and 
Bickersteth^  have  especially  directed  attention  to  this 
subject  in  a  series  of  most  interesting  cases.  In  none 
of  these,  however,  did  th^  irritation  assume  a  central 
character.  But  that  cases  do  occasionally  occur  in  which 
in  consequence  of  lesion  of  the  digital  nerves  by  bruise 
or  crush,  symptoms  of  progressive  mischief  of  the  cen- 
tral portions  of  the  nervous  system  may  develop  them- 
selves is  as  undoubted,  as  it  is  pathologically  interesting 
and  clinically  important. 

That  irritation,  whether  it  be  physiological,  traumatic, 
or  pathological,  of  the  periphery  of  a  nerve  may  give 

*  "  Liverpool  Medical  and  Surgical  Reports,"  vol.  iii,  p.  64. 


CONCUSSION   OF  THE   SPINE.  203 

rise  to  acute  disease  in  the  nervous  centres,  is  familiarly 
illustrated  by  the  convulsions  of  dentition,  by  tetanus 
induced  by  the  wound  of  a  nerve  in  the  foot  or  hand, 
and  by  muscular  contractions  dependent  upon  intestinal 
irritation.  It  is  also  a  fact  admitted  by  physiologists, 
that  the  lesion  of  a  nerve-trunk  may  be  propagated 
upwards  to  the  cord,  and  produce  secondary  disease 
there.  There  is  a  class  of  cases,  however,  occasionally 
occurring  in  surgery  of  which  I  have  now  seen  several 
instances,  in  which  it  would  appear  that  the  injury  done 
to  the  peripheral  termination  of  a  nerve  in  one  of  the 
extremities,  may  induce  slow  and  progressive  disease, 
leading  on  to  structural  changes  of  a  chronic  character 
in  the  brain  and  spinal  cord,  rather  than  those  which 
take  the  form  of  acute  convulsions  or  tetanic  attacks. 
These  cases  are  important,  not  only  in  their  clinical  and 
pathological,  but  in  their  medico-legal  aspect.  The  fol- 
lowing is  a  good  illustration  of  them. 

Case  50. — Crushed  finger — Tetanic  Spasms — Symp- 
toms of  Cerebral  Softening — Death. — A  gentleman,  aged 
60,  in  good  health,  when  traveling  to  the  city  on  March 
24,  1866,  on  one  of  the  suburban  lines  of  railway,  had 
one  of  his  fingers  crushed  between  the  door  and  its 
frame  on  the  hinge  side.  The  accident  gave  rise  to 
great  pain  and  some  loss  of  blood.  The  sufferer 
returned  home  faint  and  exhausted  with  the  shock. 
He  was  seen  and  the  finger  dressed  by  Dr.  Wightman; 
who  found  there  had  been  considerable  contusion  and 
laceration  of  its  extremity,  but  that  the  bones  were 
uninjured.  The  wound  healed  slowly  but  satisfactorily, 
yet  the  patient,  who  was  in  robust  health  and  weighed 
about  twenty  stone  at  the  time  of  the  accident,  lost 
flesh,  became  weak,  and  never  seemed  completely  to 
rally  from  the  shock  he  had  sustained.  In  the  course 
of  a  month,  twitchings,  shooting  pains,  and  cramps  in 
the  arm,  somewhat  resembling  slight  tetanic  spasms, 
developed  themselves.  On  April  29  he  had  a  slight  fit. 
This  was  followed  by  numbness,  sensations  of  pins  and 
needles  in  the  hand  and  arm,  twitchings  of  the  face,  a 
sense  of  weariness  and  of  weakness,  and  although  he 
had  previously  to  the  accident  been  a  strong  man,  he  was 


204  COMPLICATIONS   OF 

now  unable  to  undergo  even  slight  exertion  without 
much  feeling  of  fatigue.  He,  however,  returned  to  his 
business  as  a  house  agent,  and  for  six  months  continued 
it  intermittently.  He  was  then  obliged  to  relinquish 
it,  grew  slowly  and  gradually  worse,  and  eventually 
died,  with  symptoms  of  cerebral  softening,  on  Septem- 
ber 13,  1867, 

Previously  to  this  he  had  been  seen  by  Mr.  Le  Gros 
Clark,  and  a  consultation  had  been  arranged  on  the  day 
of  his  death,  which  was  sudden.  The  question  arose 
as  to  how  far  these  symptoms  were  connected  with  the 
accident,  and  after  a  careful  review  of  all  the  circum- 
stances of  the  case,  we  came  to  the  opinion  that  the 
injury  received  in  the  hand  was  the  exciting  cause  of 
the  affection  of  the  nervous  system  which  ultimately 
resulted  in  his  death.  The  circumstances  that  mainly 
led  to  this  conclusion  were  the  following:  That  up  to 
the  time  of  the  accident  the  patient  had  been  in  robust 
health ;  that  the  injury  was  immediately  followed  by 
severe  and  prolonged  nervous  shock,  and  by  signs  of 
local  nervous  irritation  in  the  arm ;  that  he  never  sub- 
sequently recovered  from  these  symptoms,  which  were 
continuous,  without  a  break,  and  though  at  times  some- 
what fl'uctuating  weie,  upon  the  whole,  slowly  progres- 
sive, the  disease  which  originated  in  the  injury  having, 
in  point  of  fact,  an  uninterrupted  history  from  its 
origin  to  its  fatal  termination;  that  the  hand  and  arm 
of  the  injured  limb  were  the  primary  seats  of  the  local 
disease  which  spread  upwards  to  the  nervous  centres ; 
and  that  death  resulted  from  cerebral  disease  which 
presented  all  the  signs  of  softening  of  the  brain. 

The  widow  of  the  patient  brought  an  action  against 
the  Company,  under  Lord  Campbell's  Act,  and  obtained 
a  verdict. 

Since  this  case  occurred  I  have  seen  at  least  two 
very  similar  to  it.  In  one  of  these  a  medical  man  sus- 
tained an  injury  of  the  finger;  this  was  followed  by 
pains  and  convulsive  twitches  in  the  arm,  a  progressive 
breakdown  in  health,  and  death  in  about  a  year.  We 
have  yet  to  learn  the  history  of  the  future  of  patients 
who  have  suffered  disorganizing  injuries  or  been  sub- 


CONCU SSi( JN   OF   THE    SPINE.  205 

jected  to  serious  operations  on  the  extremities.  Recov- 
ery from  accident  or  operation  does  not  necessarily 
imply  complete  restoration  to  previous  state  of  health 
or  the  prospect  of  prolonged  life. 

It  need  scarcely  be  said  that  any  ordinary  surgical 
injury  to  the  head,  trunk,  or  limbs  may  complicate  the 
effects  of  a  concussion  of  the  spine.  As  has  already 
been  stated  (Lecture  VII.)  the  usual  symptoms  of  ner- 
vous shock  arising  from  spinal  concussion  are  less  marked 
in  the  majority  of  those  cases  In  which  there  is  a  severe 
physical  lesion  elsewhere.  But  yet  Instances  of  this 
complication  are  not  very  unfrequent.  I  have  seen 
many.  There  Is  this  Important  practical  point  con- 
nected with  them,  that  In  consequence  of  the  depressed 
vital  power  of  the  limbs — their  coldness,  the  feebleness 
of  the  circulation,  and  the  loss  of  innervation — repair 
of  injury  in  these  cases  is  far  slower  than  under  ordi- 
nary circumstances.  This  is  especially  the  case  In  the 
lower  extremities.  Wounds,  even  though  of  a  very 
superficial  character,  being  little  more  than  abrasions, 
will  heal  very  slowly — months  being  occupied  in  the 
repair  of  a  lesion  that  would  In  a  strong  and  healthy 
person  require  only  weeks.  Thus  union  of  fractures  is 
also  delayed,  and  the  callus,  when  formed,  is  soft  and 
yielding.  In  contusions  of  the  limbs  the  extravasated 
blood  is  but  slowly  absorbed,  and  the  part  struck  may 
long  continue  to  be  the  seat  of  coldness  and  neuralgic 
pain.  The  vaso-motric  actions  may  be  seriously  dis- 
turbed ;  the  limbs  becoming  deeply  congested,  cold  and 
oedematous.  This  state  of  things  may  last  for  many 
months,  and  may  possibly  in  some  instances  be  depend- 
ent on  deep-seated  venous  embolism. 


LECTURE    X. 

IMPAIRMENT   OF  VISION    COMPLICATING    INJURIES   OF 
THE   NERVOUS   SYSTEM. 

The  eye  often  suffers  from  injuries  of  the  nervous 
system.  It  may  suffer  primarily  by  the  same  violence 
that  affects  the  head  or  spine,  or  it  may  be  secondarily 
affected  in  two  distinct  ways ;  either  by  injury  to  its 
delicate  organisation,  direct  or  indirect,  or  by  some 
reflex  action  dependent  on  the  disturbance  of  the  action 
of  the  nervous  system,  spinal  or  ganglionic.  The 
varions  affections  of  the  eye  that  may  thus  be  developed 
are  all  necessarily  accompanied  by  more  or  less  impair- 
ment of  vision,  or  even  by  its  complete  loss.  This  is 
the  sign  by  which  the  damage  to  the  eye  is  usually  at 
once  recognized,  and  it  is  this  impairment  that  consti- 
tutes the  great  importance  of  injuries  to  the  eyeball. 

These  various  injuries  will  therefore  be  considered 
as  giving  rise  to  this  particular  symptom  or  effect  ; 
and  wc  shall  proceed  to  study  "  impairment  of  vision" 
as  it  arises  from  the  following  nervous  lesions : 

I.  Concussion  of  the  eyeball,  and  direct  shock  to 
the  optic  nerve. 

b.  Injury  of  the  face,  implicating  the  branches  of 
the  fifth  nerve. 

3.  Injury  of  the  spinal  cord. 

4.  Injury  of  the  sympathetic  nervous  system. 

I.  Conaission  of  Eyeball. — The  impairment  of  vision 
that  arises  from  simple  concussion  of  the  eyeball  occurs 
immediately  on  the  receipt  of  the  injury.  It  is  at  its 
worst  at  the  moment  of  the  occurrence,  and  may  either 
slowly  disappear  or  become  permanent,  in  consequence 
of  the  ultimate  development  of  secondary  changes  in 
the  structure  of  the  globe,  by  which  complete  destruc- 
tion of  vision  may  ultimately  be  produced,  either  by 
changes  taking  place  in  the  retina  or  choroid,  or  by 
the  development  ot  cataract. 

This  concussion  of   the  globe  may  be  produced  in 


COMPLICATING   IN7URIES.  207 

two  ways.  i.  By  a  direct  blow  upon  it.  2.  By  a  blow 
on  the  head  or  face,  but  not  actually  on  the  eyeball  itself. 
A  smart  direct  blow  on  the  eyeball  may  at  once 
paralyse  the  retina  without  giving  rise  to  any  organic 
mischief,  laceration  of  tissue,  or  effusion  of  blood  in 
the  eyeball  itself.  In  this  way  it  illustrates  forcibly  and 
resembles  closely  the  effect  of  a  blow  on  the  head  that 
occasions  concussion  of  the  brain  without  organic 
injury  of  the  cerebral  substance. 

The  following  case  illustrates  such  an  injury  and  its 
effects : 

A  gentleman,  about  30  years  of  age,  in  full  health 
and  vigor,  whilst  in  a  booth  at  Ascot  Races,  was  struck 
full  in  the  right  eye  by  the  cork  of  a  champagne  bottle. 
He  felt  faint,  sick,  and  was  slightly  collapsed.  He  imme- 
diately lost  the  sight  of  the  eye  struck.  He  came  up 
to  London  at  once.  I  saw  him  the  same  evening,  about 
four  hours  after  the  accident.  He  was  still  faint  and 
suffering  from  nervous  depression.  On  examining  the 
eye  the  pupil  was  found  to  be  widely  dilated,  so  that 
the  iris  formed  a  very  narrow  linear  circle  round  it, 
slightly  broader  towards  the  inner  than  the  outer  side. 
All  power  of  distinct  vision  was  lost,  but  the  patient 
could  distinguish  the  light.  The  dilated  pupil  was 
quite  immovable.  The  pupil  of  the  uninjured  eye  acted 
well  as  soon  as  the  shock  was  recovered  from.  I  ordered 
rest  in  a  darkened  room  ;  cold  evaporating  lotions  to 
the  eye  ;  purges  ;  moderate  diet. 

Mr.  Critchett  co-operated  with  me  in  the  manage- 
ment of  the  case.  He  made  a  very  careful  ophthalmo- 
scopic examination,  but  could  detect  no  sign  of  internal 
injury,  or  of  extravasation  into  the  globe.  After  a  time 
Calabar  bean  was  applied  to  the  eye,  and  the  pupil,  after 
continuing  dilated  for  some  weeks,  began  slowly  to  con- 
tract, vision  returning  in  proportion  as  it  did  so. 

Here  was  a  case  of  simple  nervous  shock  to  the 
eyeball,  producing  paralysis  of  the  optic  nervous  appa- 
ratus, attended  in  the  first  instance  by  evidence  of 
shock  to  the  nervous  system,  and  but  slowly  and  gradu- 
ally subsiding. 

It  is  a  fact  well  known  to  all  practical  surgeons  that 


208  IMPAIRMENT    (JF   VISION 

a  blow  on  the  head  or  face  may,  without  impinging  on 
the  eyeball,  so  severely  shake  or  concuss  the  globe  that 
vision  becomes  seriously  and  perhaps  permanently 
affected.  In  these  cases  the  injury  done  to  the  eye  is 
mechanical.  It  is  dependent  on  concussion  transmitted 
through  the  bones  of  the  head  or  face  to  the  structures 
within  the  orbit. 

That  such  concussion  may  occasionally  be  productive 
of  serious  injury  to  the  structures  of  the  globe,  is 
evident  from  the  fact  that  dislocation  of  the  lens  has 
been  known  to  occur  as  a  consequence  of  such  shock, 
without  any  direct  injury  having  been  inflicted  on  the 
eyeball  itself. 

Dr.  D'Eyber  (Gazette  Medicale  de  Paris,  1840) 
relates  the  case  of  a  patient  who  became  affected  by 
cataract  in  consequence  of  the  wound  of  the  eyebrow 
by  a  stone,  without  any  injury  to  the  eye  itself.  And 
I  have  seen  cataract  developed  three  or  four  months 
after  the  receipt  of  a  blow  on  the  malar  prominence 
and  eyebrow,  received  in  a  railway  collision  by  a  woman 
otherwise  healthy,  about  40  years  of  age,  without  any 
injury  having  been  sustained  .directly  by  the  eye  itself. 

In  this  case,  which  was  seen  and  most  carefully 
examined  by  two  distinguished  ophthalmic  surgeons, 
Messrs.  Hancock  and  Haynes  Walton,  as  well  as  by 
myself,  it  was  evident  that  the  concussion  which  the 
head  generally  had  sustained  had  so  jarred  the  lens  that 
its  nutrition  was  interfered  with,  and  a  cataractous  con- 
dition became  slowly  developed. 

If  such  serious  organic  mischief  can  declare  itself 
in  the  interior  of  the  globe  as  a  consequence  of  a 
general  jar  or  shake  of  the  head,  it  is  not  unreasonable 
to  suppose  that  in  many  of  those  cases  that  we  witness, 
in  which,  after  a  general  shock  to  the  system,  obscura- 
tion and  impairment  of  vision  gradually  manifest  them- 
selves, and  in  which  white  atrophy  of  the  optic  disc  is 
discovered  by  ophthalmoscopic  examination,  the  injury 
to  the  eye,  functional  and  organic,  is  due  to  a  shake  or 
jar  of  its  nervous  structures,  by  which  their  nutrition 
becomes  seriously  but  slowly  impaired,  and  organic 
changes  become  secondarily  developed  in  them. 


COMrLICATING    INJURIES.  209 

In  this  Way  we  can  account  for  cataract  developing 
itself  as  the  result  of  blows  on  the  eyebrows  or  cheeks. 
Branches  of  the  fifth  pair  of  nerves,  whether  frontal  or 
infra-orbital,  becoming  implicated  and  irritated,  and 
the  nutrition  of  the  globe  being  subsequently  impaired 
in  a  way  that  will  be  described  in  the  next  section. 

2.  From  hijurics  of  the  ^th  Pair  of  Nerves. — But 
independently  of  the  indirect  infliction  of  shock  thus 
transmitted  to  the  delicate  structures  of  the  eyeball 
from  blows  on  the  surrounding  and  neighbouring  osseous 
prominences,  there  is  yet  another  way  in  which  the 
eye  may  suffer  secondarily  from  injuries  of  the  face, 
viz.,  in  consequence  of  wound  or  irritation  of  the 
branches  of  the  fifth  pair  of  nerves.  There  are  nume- 
rous scattered  cases  proving  clearly  that  wounds  of  the 
eyebrow  or  of  the  cheek,  and  even  severe  contusions 
of  these  parts,  have  been  followed  by  impairment,  and 
eventually  by  loss  of  vision. 

This  observation  dates  from  the  very  earliest  records 
of  medicine.  It  is  as  old  as  the  writings  of  Hippocrates, 
who  speaks  of  loss  of  vision  consequent  on  wounds  of 
the  eyebrow,  and  who  makes  the  very  accurate  and 
pertinent  observation,  that  vision  is  less  impaired  when 
the  wound  is  recent,  but  that  it  becomes  progressively 
worse  as  cicatrisation  becomes  older. 

Many  of  the  older  writers  mention  cases  illustrative 
of  the  loss  of  vision  after  injuries  of  the  eyebrow.  Fab- 
ricius  Hildanus  and  La  Motte  both  relate  cases  in  which 
blindness  followed  wounds  of  the  outer  angle  of  the 
orbit.  Morgagni  relates,  on  the  authority  of  Valsalva, 
the  case  of  the  wife  of  a  surgeon  who  was  wounded  on 
the  eyelid  by  the  spur  of  a  cock.  Vision  was  immedi- 
ately lost,  but  eventually  recovered  by  the  use  of  friction 
over  the  infra-orbital  nerve.  This  was  probably  rather 
a  case  of  concussion  of  the  eyeball  than  of  sympathetic 
amaurosis.  Morgagni  relates  another  case,  that  of  a 
lady  who,  in  consequence  of  the  upsetting  of  a  carriage, 
was  wounded  by  some  splinters  of  glass  in  the  upper 
eyelid.  There  was  no  injury  to  the  eyeball,  but  still 
vision  became  gradually  impaired,  so  that  by  the  fortieth 
day  after  the  accident  it  was  almost  completely  lost. 
H 


2IO  IMPAIRMENT    OF    VISION 

Wardrop  (on  the  Morbid  Anatomy  of  the  Human 
Eye,  vol.  ii.  p.  194,  et  seq.  Lond.  1834)  relates  several 
cases  in  which  wounds  of  the  branches  of  the  fifth  were 
followed  by  loss  of  vision.  Thus,  a  gentleman  received 
an  oblique  cut  in  the  forehead,  which,  from  its  direction, 
must  have  injured  the  frontal  nerve.  It  was  not  accom- 
panied by  any  bad  symptoms,  and  soon  healed.  But 
the  vision  became  gradually  impaired,  and  in  a  few 
months  was  completely  lost. 

A  sailor  was  struck  by  a  ramrod  on  the  eyebrow, 
where  the  frontal  nerve  passes  out.  Vision  was  imme- 
diately lost  and  was  never  regained. 

An  officer  at  the  siege  of  Badajos  was  struck  by  a 
piece  of  shell  on  the  eyebrow,  over  the  course  of  the 
frontal  nerve.  Vision  became  gradually  imperfect,  and 
in  a  few  months  was  completely  lost. 

Wounds  of  the  infra-orbital  nerve  are  also  sometimes 
followed  by  loss  of  vision.  Wardrop  and  Beer  both 
mention  cases  of  this  kind. 

To  this  category  also  belong  those  cases  in  which  the 
patient  becomes  amaurotic  from  irritation  of  the  dental 
nerves  by  the  crowding  of  teeth,  by  pivoting  a  tooth, 
by  caries,  or,  as  in  the  case  related  by  Dr.  Galezowski 
(Arch,  gen,  de  Med.),  in  which  a  wooden  tooth-pick, 
broke  and  lodged  in  a  carious  tooth,  produced  amau- 
rosis, which  was  cured  by  the  extraction  of  the  tooth. 
I  have  seen  amaurosis  follow  the  extraction  of  a  nasal 
polypus. 

That  a  simple  contusion  of  the  eyebrow,  without 
wound  of  any  kind,  may  produce  amaurosis,  is  positively 
stated  by  Chelius,  who  says :  ''  I  have  seen  a  case  of 
complete  amaurosis  occur  suddenly  eight  days  after  a 
blow  on  the  region  of  the  eyebrow,  though  there  was 
not  any  trace  of  it  on  the  skin.  The  pupil  was  natural 
and  movable,  and  there  was  not  the  slightest  pain." 
(South's  translation  of  CheHus'  System  of  Surgery,  vol. 
i.  p.  430.) 

Rondeau  (Affections  oculaires  reflexes,  p.  53  ;  Paris, 
1866),  relates  two  cases  that  illustrate  this  subject.  The 
first  is  that  of  a  saddler,  who  in  falling  received  a  wound 
on  the  left  eyebrow.     This  wound  was  followed  by  photo- 


COMPLICATING   INJURIES.  211 

phobia  and  lachrymation  of  the  left  eye,  and  without 
any  pain,  by  gradual  loss  of  vision  in  it,  at  the  end  of 
three  months.  The  ball  became  flaccid  and  atrophied, 
the  sclerotic  yellowish  in  tint,  the  iris  discolored,  and 
the  pupil  immovable.  Fifteen  years  afterwards  the 
right  eye  became  similarly  affected,  and  in  eight  or  ten 
months  he  became  completely  blind. 

The  second  case  related  by  Rondeau  is  that  of  a 
bathman,  who  was  wounded  on  the  left  eyebrow  by  some 
fragments  of  broken  porcelain.  The  resulting  cicatrix 
became  the  seat  of  continued  dull  aching  pains,  inter- 
mixed with  lancinating  neuralgic  seizures,  extending 
over  the  left  side  of  the  cheek  and  head.  Three  weeks 
after  the  accident  the  sight  of  the  left  eye  began  to  fail, 
objects  became  cloudy  and  indistinct.  This  increased, 
so  that  in  six  weeks  vision  was  completely  lost.  About 
this  time  the  right  eye  became  affected  with  photopho- 
bia, deep-seated  pain,  and  impairment  of  vision.  On 
ophthalmoscopic  examination  of  the  left  eye  it  was 
found  that  the  retina  was  congested,  large  venous 
trunks  being  seen  to  enter  it  here  and  there.  The  retina 
had  lost  its  transparency,  especially  around  the  central 
spot,  the  borders  of  which  were  ill-defined.  The  general 
color  of  the  bottom  of  the  eye  had  lost  its  brightness, 
so  that  the  choroid  was  partly  marked  by  the  prevailing 
greyish  tint.  The  same  appearances  were  found  in  the 
right  eye,  but  to  a  less  marked  extent,  the  retina  being 
brighter  and  more  natural  in  color. 

From  all  this  it  is  evident  that  amaurosis  has  been 
frequently  observed  to  follow  injuries  of  the  eyebrow 
and  side  of  the  face.  It  is  by  no  means  necessary  that 
a  wound  should  have  been  inflicted,  a  simple  contusion 
is  sufficient. 

Wardrop  makes  the  very  important  observation  {loc. 
cit.  p.  193)  that  it  is  only  when  the  frontal  nerve  is 
wounded  or  injured,  and  not  divided,  that  amaurosis 
takes  place.  Indeed,  in  some  cases  the  amaurosis  has 
been  cured  by  making  a  complete  division  of  the  nerve, 
as  Rondeau  states  was  done  by  Dr.  Eller  in  a  case  of 
amaurosis  following  concussion  of  the  frontal.  In  fact 
it  appears  to  be  irritation  of  a  branch  of  the  fifth,  as  in 


212  IMPAIRMENT   OF   VISION 

lacerated  wounds,  in  dental  caries,  and  not  its  clean  and 
complete  section,  that  disposes  to  amaurosis. 

This  is  in  accordance  with  the  view  expressed  by 
Brown-Sequard,  who  states  that  "  the  immediate  effects 
of  the  section  of  a  nerve,  or  its  absence  of  action,  are 
very  different  from  those  that  are  observed  as  the  result 
of  its  irritation  ;  that  is  to  say,  of  its  morbid  action, 
which  gives  rise  to  veritable  derangements  in  the  nutri- 
tion of  the  part  supplied  by  it."  (Journal  de  Physi- 
ologic.) 

The  loss  of  vision  may  come  on  instantaneously,  as 
in  the  case  related  by  Wardrop  of  the  sailor  struck  by 
a  ramrod  on  the  eyebrow,  or  after  the  lapse  of  a  few 
days,  as  in  the  case  recorded  by  Chelius,  where  the  loss 
of  vision  came  on  eight  days  after  a  blow  on  the  eye- 
brow. Or  after  a  longer  lapse  of  time,  as  in  most  of  the 
recorded  cases.  In  the  great  majority  of  cases  the 
impairment  of  vision  is  at  first  slight,  and  gradually  goes 
on  to  complete  loss  of  sight. 

The  fact  then  being  incontestably  established  that 
loss  of  vision  may  follow  a  contusion  or  wound  of  the 
eyebrow  or  cheek,  irritating  and  injuring  one  of  the 
branches  of  the  fifth  pair  of  nerves,  the  question  that 
naturally  presents  itself  is,  in  what  way  can  the  irrita- 
tion of  a  distant  branch  of  the  trifacial  nerve,  unaccom- 
panied by  any  direct  injury  of  the  eyeball  or  of  the 
structure  of  the  orbit,  produce  instantaneously,  or 
remotely,  loss  of  vision? 

Some  observers,  who  have  noticed  the  occurrence  of 
amaurosis  after  injury  to  the  branches  of  the  fifth 
nerve,  have  attributed  this  to  the  propagation  of  irrita- 
tion along  the  sheath  of  the  nerve,  until  it  reaches  the 
trunk  of  the  ophthalmic  division,  whence  it  extends  to 
the  sheath  of  the  optic  nerve  and  to  the  retina.  But 
there  is  no  evidence  of  the  propagation  of  such  inflam- 
mation, and,  in  any  case,  this  would  be  an  insufficient 
mode  of  explaining  those  cases  in  which  blindness  had 
suddenly  supervened. 

That  the  section  of  the  trunk  of  the  fifth  nerve  pro- 
duces important  changes  in  the  eye  is  well  known  to 
physiologists,  and  has  been  incontestably  determined 


COMPLTCATINCx   INJURIES.  213 

of  late  years  by  the  experiments  of  Snellen,  Schiff,  and 
others.  And  whether  these  experiments  explain  the 
morbid  changes  that  occur  in  the  eye  as  a  consequence 
of  the  section  of  this  nerve  by  the  supposition  that 
*' neuro-paralytic  "  inflammation  is  set  up  in  the  globe, 
or  that  the  surface,  by  losing  its  sensibility,  becomes 
more  liable  to  the  action  of  external  irritants,  matters 
little  to  the  practical  surgeon  ;  they  at  least  serve  to 
establish  more  fully  the  clinical  fact  previously  ascer- 
tained."^ 

Wardrop  says,  "  The  distribution  of  the  first  branch 
of  the  fifth  pair,  or  ophthalmic  branch,  explains  how 
.  .  .  wounds  of  the  frontal,  infra-orbital,  and  other 
branches  of  nerves  which  form  anastomoses  with 
the  ophthalmic  ganglion,  are  sometimes  followed  by 
amaurosis."  And  no  doubt  he  is  correct ;  and  that 
it  is  in  this  anatomical  arrangement  that  we  must  find 
the  solution  of  what  is  certainly  a  surgical,  or  rather  a 
physiological  riddle.  It  is  to  the  intimate  connection 
that  exists  between  the  frontal  nerve,  which  is  the 
direct  continuation  of  the  ophthalmic  division  of  the 
fifth  with  the  sympathetic  and  the  ciliary  nerves,  that 
we  must  refer  these  various  morbid  phenomena  result- 
ing from  irritation.  Whether  this  irritation  of  the 
frontal  exercises  an  injurious  influence  by  causing  a 
hyperaemic  state  of  the  vessels  of  the  retina  and  iris  is 
doubtful,  but  the  fact,  as  the  result  of  clinical  observa- 

*Meynert  has  described  a  root  of  the  trigeminus  nerve  as  proceeding 
from  the  anterior  ganglion  of  the  corpora  quadrigemina,  which  is  char- 
acterised by  containing  large  vesicular  cells.  1'his  he  regards  as  the 
anterior  sensory  root  of  the  fifth  nerve.  Merkel,  who  has  examined 
the  subject  more  recently,  has  arrived  at  the  same  conclusion  as  Mey- 
nert  in  regard  to  its  origin,  but  believes  that  the  function  of  the  root  is 
tro])hic,  not  sensory.  Merkel  founds  his  opinion  partly  on  pathological 
evidence,  which  indicates  that  the  trophic  disturbances  in  the  eye  after 
injury  to  the  fifth  nerve  may  have  a  cerebral  origin,  and  partly  on 
physiological  experiment.  In  the  rabbit  the  root,  from  the  quadrigemi- 
ral  origin  of  the  fifth,  does  not  fuse  with  the  sensory  root  of  the  fifth, 
but  runs  separately  along  the  median  side  of  this  root.  In  an  experi- 
ment he  made,  whilst  the  sensory  root  of  the  fifth  was  destroyed,  this 
portion  was  uninjured,  and  only  very  transitory  trophic  disturbance  was 
the  result,  If  these  observations  be  correct,  it  follows  that  trophic 
changes  in  the  eyeball  will  occur  only  when  the  quadrigeminal  root  of 
the  fifth  is  affected. 


214  IMPAIRMENT   OF   VISION 

tion,  is  certain,  that  in  some  cases  it  is  the  primary  and 
determining  cause  of  loss  of  vision. 

3.  Impairment  of  Vision  from  Spinal  Injury . — One  of 
the  most  frequent  and  most  troublesome  effects  of 
spinal  injury  is  a  certain  degree  of  impairment  of  vision. 

This  may  assume  different  characters  at  different 
periods  after  the  injury,  and  may  come  on  at  any 
time  afterwards.  As  we  have  just  seen  in  cases  in 
which  amaurosis  follows  injury  of  the  supra-orbital 
nerve,  so  in  the  instances  in  which  impairment  of 
vision  follows  spinal  injury,  some  considerable  in- 
terval often  intervenes  between  the  occurrence  of 
the  injury  and  the  development  of  the  eye  symptoms. 
This  is  by  no  means  necessarily  so,  but  it  does  often 
happen,  and  if  in  consequence  of  bodily  suffering 
or  weakness  the  patient  be  confined  to  bed,  and 
be  not  called  upon  to  use  his  eyes,  it  may  be  long 
before  he  discovers  that  his  vision  is  enfeebled.  This 
is  particularly  apt  to  be  the  case,  as  the  attention  of 
the  surgeon  may  not  be  directed  to  the  state  of  the 
eyes  in  the  first  instance,  the  symptoms  being  entirely 
subjective,  and  there  being  no  external  evidence  of  any- 
thing wrong  with  the  eyes. 

The  first  and  most  frequent  symptom  that  is  com- 
plained of,  is  a  dimness  or  weakness  of  the  sight,  so 
that  the  patient  cannot  define  the  outlines  of  small  ob- 
jects, and  cannot  see  in  an  obscure  light.  If  he  attempt 
to  read,  he  can  define  the  letters  often  even  of  the 
smallest  print  for  a  few  seconds  or  minutes,  but  they 
soon  run  into  one  another,  become  obscured  and 
blurred  and  ill-defined.  Glasses  do  not  materially,  if 
at  all,  improve  this  condition.  There  is  often  in  the 
early  stages  a  certain  amount  of  double  vision — usually 
associated  with  slight  irregularity  in  the  axes  of  the 
eyes,  scarcely  amounting,  however,  to  a  squint.  This 
blurring  or  indistinctness  of  vision  is  often  more 
observable  with  respect  to  near  than  to  distant  objects. 
After  a  time  the  patient  usually  begins  to  suffer  from 
irritability  of  the  eyes  in  addition  to  the  impairment  of 
sight.  He  cannot  bear  a  strong  light,  not  even  that  of 
an  ordinary  window,  in  the  daytime ;  he  sits  with  his 


COMPLICATING   INJURIES.  21$ 

back  turned  towards  it,  or  has  it  shaded.  He  cannot 
bear  unshaded  gas  or  lamp-Hght.  In  consequence  of 
this  irritability  of  the  eyes  the  brows  are  involuntarily 
contracted,  and  the  patient  acquires  a  peculiar  frown  in 
order  to  exclude  the  light  as  much  as  possible  from  the 
eyes.  This  intolerance  of  light  may  amount  to  perfect 
photophobia,  and  is  then  associated  with  a  congested 
state  of  the  conjunctiva,  and  accompanied  by  lachry- 
mation. 

One  or  both  eyes  may  be  thus  affected.  Sometimes 
one  eye  only  is  intolerant  to  light.  This  intolerance  to 
light  is  associated  with  impairment  of  vision.  It  is 
usually  accompanied  by  muscse  volitantes  and  spectre- 
rings  ;  and  stars,  spots,  flashes,  and  sparks,  white- 
colored  and  flame-like,  are  also  complained  of.  The 
appearance  of  a  fixed  luminous  spectrum — a  line, 
circle,  or  colored  bar — across  the  field  of  vision  is 
sometimes  complained  of.  There  is  an  undue  reten- 
tion of  images  in  many  cases,  and  when  the  patient  has 
looked  at  any  bright  object,  the  sun  or  the  fire,  supple- 
mentary spectral  colors,  often  of  the  most  beautiful 
character,  of  varying  degrees  of  intensity,  will  develop 
themselves  in  succession.  The  patient  becomes,  in 
some  cases,  conscious  of  the  circulation  in  his  own  eye. 
which  becomes  visible  to  him. 

Double  vision  is  frequent  with  both  eyes  open.  But 
there  may  be  double  or  even  treble  vision  with  one  eye. 
A  patient  may  see  two  lights,  or,  perhaps,  two  lights 
distinctly  and  the  shadow  of  a  third,  with  one  eye  only. 
This  happens  independently  of  injuries  to  the  nervous 
system,  but  has  often  been  denied,  and  I  have  known  a 
patient  stigmatized  as  an  imposter  because  he  said  he 
had  double  vision  with  one  eye.  But  I  am  acquainted 
with  two  medical  men  who  suffer  from  this  peculiarity. 
This  double  or  even  treble  vision  with  one  eye  is  now 
recogni;fed  by  ophthalmologists  as  a  distinct  affection, 
under  the  term  polyopia  monophthalmica.  I  know 
not  the  explanation,  but  of  the  fact  I  am  certain. 

In  other  cases  the  patient  loses  the  power  of  cor- 
rectly judging  of  the  distance  both  of  near  and  far 
objects. 


2l6  IMPAIRMENT   OF   VISION 

From  the  description  of  the  various  symptoms  of  the 
impairment  of  vision  that  supervene  on  spinal  injury, 
it  would  appear  that  the  failure  of  sight  may  arise  from 
one  of  four  conditions,  or  from  a  combination  of  two  or 
more  of  these.  Mr.  John  Tweedy,  who  has  paid  much 
attention  to  this  important  subject,  has  favored  me 
with  the  following  lucid  explanation  of  the  ocular  phe- 
nomena attendant  on  spinal  concussion :  There  is, 
firstly,  asthenopia,  or  simple  weakness  of  sight ;  the  pa- 
tient is  unable  to  accommodate  for  near  objects  for 
more  than  a  few  minutes.  Either  the  nerve-supply  to 
the  ciliary  muscle  is  impaired,  so  that  the  muscle  soon 
becomes  fatigued  and  is  unable  to  maintain  sufficient 
tension  to  keep  the  crystalline  lens  properly  adjusted, 
or  there  is  weakness  of  one  or  both  of  the  internal  recti 
muscles,  and  the  patient  cannot,  consequently,  keep  up 
due  convergence  of  the  eyes — an  essential  element  in 
the  adjustment  of  the  eyes  for  near  objects.  Associ- 
ated with  either  or  both  of  these  may  be,  secondly,  a 
certain. degree  of  amblyopia,  a  paresis  of  the  retina  or 
optic  nerve.  The  retina  may  be  capable  of  receiving 
for  a  time  accurate  impressions,  which  may  be  readily 
transmitted  along  the  optic  nerve  to  the  brain,  but, 
sooner  or  later,  a  state  of  exhaustion  is  induced,  a  state 
not  unlike  the  "  pins  and  needles  "  experienced  in  other 
weakened  or  injured  sensory  nerves.  Thirdly,  the 
power  of  accommodation  of  the  eye  may  be  completely 
lost,  the  patient  being  quite  unable  to  read  or  write,  or 
to  see  clearly  any  near  object,  although  the  retina  and 
optic  nerve  may  be  quite  healthy  and  distant  vision 
normal.  It  is  desirable  that  this  condition  should  be 
recognized,  as  it  has  an  important  bearing  on  prognosis 
and  treatment.  For  instance,  it  sometimes  happens 
that  a  short  time  after  the  receipt  of  an  injury  to  the 
head  or  spine  a  patient  finds  that  he  is  unable  to  see  to 
read  or  write,  but  that  his  distant  vision  remains  good. 
Unless  great  care  be  exercised,  this  condition  may  be 
taken  as  indicative  of  commencing  amaurosis.  If,  how- 
ever, a  little  of  the  extract  of  calabar  bean  be  instilled, 
tension  of  the  accommodative  apparatus  is  induced, 
and,  for  the  time,  vision  for  near  objects  is  good,  and, 


'      COMPLICATING   INJURIES.  217 

may  be,  normal.  If  there  be,  in  addition  to  the  paraly- 
sis of  accommodation,  some  anomaly  of  refraction, 
hypermetropia,  myopia,  or  astigmatism,  separately  or 
conjointed,  matters  are  still  worse.  If  hypermetropia 
exist,  the  distant  vision  will  also  be  impaired  when  the 
power  of  accommodation  is  lost,  for  then  even  parallel 
rays  of  light  are  not  sufficiently  converged  to  come  to  a 
focus  on  the  retina,  and  circles  of  diffusion  are  formed. 
If  astigmatism  be  present,  the  optical  inconveniences 
with  which  this  condition  is  always  attended  are  greatly 
increased  by  failure  of  accommodation.  If,  then,  any 
of  these  anomalies  exist,  properly  selected  spectacles 
will  be  necessary  to  enable  the  patient  to  see  accurately 
even  distant  objects.  It  must  not,  however,  be  for- 
gotten that  the  loss  of  power  of  accommodation  is 
always  of  grave  significance,  and  may  be  the  forerunner 
of  serious  nutrition  changes  in  the  deeper  structures  of 
the  eye,  changes  which  may  eventuate  in  blindness. 
Fourthly,  there  may  be  irritability  of  the  eye  and  pho- 
topsia  depending  on  hyperaemia  of  the  retina,  or  on 
inflammation  of  it  and  of  the  optic  nerve.  In  ordinary 
erethitic  amblyopia  the  symptoms  are  not  constant, 
but  vary  in  intensity  at  different  periods  of  the  day, 
being  usually  worst  in  the  morning.  They  vary  also 
with  the  state  of  health  and  with  the  condition  of  the 
mind,  being  less  marked  when  the  health  improves  and 
when  the  patient  is  in  good  spirits.  They  are,  more- 
over influenced  by  the  state  of  the  weather  and  sur- 
rounding circumstances,  everything  of  a  depressing 
character  having  a  tendency  to  aggravate  the  symp- 
toms. 

The  objective  appearances  presented  by  the  eye,  and 
the  ophthalmoscopic  manifestations  seen  in  the  interior 
of  the  globe  in  these  cases,  have  been  carefully  studied 
by  Mr.  Wharton  Jones  and  Dr.  Clifford  Allbutt. 

Mr.  W.  Jones,  in  his  admirable  and  scientific  work 
"On  Failure  of  Sight  after  Railway  and  Other  Inju- 
ries," states  that  the  pupils  are  usually  half  closed,  the 
eyes  sunken,  dull,  and  watery,  the  veins  of  the  eyeball 
congested.  The  movements  of  the  pupils  are  some- 
times normal,  sometimes  sluggish,  but  sometimes  more 


2l8  IMPAIRMENT   OF   VISION 

active  than  usual.  This  will  necessarily  depend  upon 
whether  the  eye  is  affected  with  simple  asthenopia,  or 
whether  there  is  some  hyperaemic  or  inflammatory  state 
already  developed  in  its  interior. 

The  ophthalmoscopic  appearances  were  found  to  vary 
greatly.  In  some  cases,  as  Mr.  Wharton  Jones  most 
justly  observes,  the  morbid  state  on  which  the  failure 
of  sight  and  other  subjective  symptoms  depend  may  be 
at  first  confined  to  some  central  portions  of  the  optic 
nervous  apparatus,  and  no  ophthalmoscopic  evidence 
of  implication  of  the  retina  or  optic  disc  may  pre- 
sent itself  till  a  more  advanced  stage  of  the  case. 
Sooner  or  later,  however,  whether  as  the  effect  of  pri- 
mary changes  in  the  fundus,  or  as  the  result  of  a  slowly 
progressive  inflammatory  affection  propagating  itself 
from  the  intra-cranial  portion  of  the  nervous  apparatus 
towards  its  periphery,  a«nd  thus  inducing  morbid  changes 
in  the  optic  nerve  and  disc,  we  find  that  the  ophthal- 
moscope reveals  changes  in  the  fundus  of  the  eye. 
"The  disc  is  seen  to  be  whitish,  and  somewhat  con- 
gested ;  the  retinal  veins  are  large,  though  the  fundus 
usually  presents  an  anaemic  aspect,  with  perhaps 
some  pigmentous  degeneration  of  the  retina  round 
the  disc." 

Dr.  Allbutt,  who  has  investigated  the  subject  with 
great  care  and  acumen,  and  in  a  truly  scientific  spirit, 
furnishes  the  following  detailed  and  accurate  account 
of  the  appearances  presented  in  these  cases,  which  I 
prefer  giving  in  his  own  words : 

'^  Having  seen,  then,  that  there  are  changes  in  the 
eye  symptomatic  of  spinal  diseases,  our  second  inquiry 
is,  Of  what  kind  are  these  changes?  Confining  our- 
selves to  the  optic  nerve  and  the  retina,  with  their  ves- 
sels, and  omitting  all  reference  to  injection  of  the  con- 
junctiva or  the  state  of  the  pupil,  what  kind  of  changes 
are  dependent  upon  disturbance  of  the  spine?  I  find 
that  they  may  be  well  classified  under  two  heads:  i. 
Simple  or  primary  atrophy  of  the  optic  nerve,  sometimes 
accompanied  at  first  by  that  slight  hyperaemia  and  in- 
active proliferation  which  make  up  the  state  I  have 
called   chronic   neuritis.     This   sort  of  change   I   have 


COMPLICATING  INJURIES.  219 

never  found  as  a  result  of  spinal  injuries,  but  I  have 
often  met  with  it  in  chronic  degeneration  of  the  cord 
and  in  locomotor  ataxy.  2.  A  somewhat  characteristic 
hypersemic  change  which  I  have  not  seen  in  chronic  de- 
generation or  in  locomotor  ataxy,  but  in  cases  of  injury 
to  the  spine  only.  The  retinal  arteries  do  not  dilate, 
but  become  indistinguishable ;  while  the  veins  begin  to 
swell  and  become  somewhat  dark  and  tortuous.  The 
disc  then  becomes  uniformly  reddened,  and  its  borders 
are  lost,  the  redness  and  pinkness  commencing  with 
increased  fine  vascularity  at  the  inner  border,  and  which 
thence  invades  the  white  centre  and  the  rest,  so  that 
the  disc  is  obscured  or  its  situation  known  only  by  the 
convergence  of  the  vessels.  In  many  cases,  rather  than 
redness,  I  have  observed  a  delicate  pink — pink  which 
sometimes  passes  into  a  daffodil  color.  In  one  case  in 
particular — a  railway  accident — which  I  examined  in 
consultation  with  my  friend  and  colleague,  Mr.  Teale, 
this  daffodil  color  of  the  whole  field  was  very  curious ; 
no  disc  was  to  be  distinguished,  but  the  dark  vessels 
stood  out  in  beautiful  relief.  The  other  eye  presented 
the  more  common  appearances  of  hyperaemia  and  serous 
effusion,  with  slight  swelling.  It  is  to  be  remarked  that 
this  state  is  generally  or  always  of  long  duration  ;  it 
passes  very  slowly  up  to  its  full  development,  and  then 
shows  a  disposition  to  end  in  resolution  rather  than  in 
atrophy.  In  those  cases  which  I  have  been  able  to 
watch  diligently  for  many  months  the  pinkness  seems 
slowly  to  have  receded,  leaving  an  indistinct  but  not 
very  abnormal  disc  behind.  Sometimes  the  sight  suf- 
fers a  good  deal  in  these  cases,  sometimes  but  little  or 
scarcely  at  all.  I  have  seen  true  optic  neuritis  with 
active  proliferation  as  a  sequel  of  spinal  disease." — 
Lancet,  1876,  vol.  i,  p.  J^-JJ. 

One  or  other  of  these  conditions  occur  In  the  majority 
of  cases  of  spinal  injury,  such  as  we  are  describing  in 
this  work.  Dr.  Allbutt  says,  "It  is  tolerably  certain  that 
disturbance  of  the  optic  disc  and  its  neighborhood  is 
.seen  to  follow  disturbance  of  the  spine  with  sufficient 
frequency  and  uniformity  to  establish  the  probability  of 
a  causal  relation  between  the  two  events."    Dr.  Allbutt 


220  IMPAIRMENT   OF  VISION 

goes  on  to  say  that  of  thirteen  cases  of  chronic  spinal 
disease  following  accidents,  he  found  eight  cases  of 
sympathetic  disorder  of  the  eye. 

My  experience  fully  accords  with  that  of  Dr.  Allbutt. 
I  find  that  in  the  vast  majority  of  cases  of  spinal  con- 
cussion unattended  by  fracture  or  dislocation  of  the 
vertebral  column,  there  occurred  after  a  few  weeks  dis- 
tinct evidence  of  impairment  of  vision. 

Dr.  Allbutt,  in  the  very  important  practical  commu- 
nication to  which  I  have  referred,  makes  the  interesting 
remark,  which  will  be  supported  by  the  experience  of 
all  surgeons,  that  in  the  severer  forms  of  spinal  injury, 
those  that  prove  fatal  In  a  few  weeks,  these  evidences 
of  eye  disease  are  not  met  with  ;  for  out  of  seventeen 
such  cases  he  found  no  evidence  of  eye  disease  In  any 
one  instance.  This  is  a  most  Important  observation, 
and  one  that  bears  strongly  on  the  cause  of  these  affec- 
tions. It  also  affords  a  most  complete  answer  to  an 
objection  that  has  often  been  urged  in  these  cases,  viz., 
that  as  sympathetic  affection  of  the  eye  Is  rarely  met 
with  In  severe  injuries  of  the  spine,  such  as  fractures 
and  displacement  of  the  vertebrae,  with  transverse  lesion 
of  the  cord,  its  occurrence  In  the  less  severe  and  more 
obscure  forms  of  Injury  can  scarcely  be  looked  upon  as 
the  direct  result  of  the  spinal  mischief.  It  would 
appear,  however,  from  the  observations  of  Dr.  Allbutt, 
which  I  can  entirely  confirm,  that  it  is  In  these  very  cases 
that  It  Is  met  with,  and  not  In  the  severe  and  rapidly 
fatal  ones. 

That  a  certain  portion  of  the  spinal  cord  exercises 
a  direct  influence  on  the  eyes,  has  been  incontestably 
established  by  the  experiments  of  modern  physiologists. 
It  has  been  long  known  that  the  upper  cervical  portion 
of  the  spinal  cord  and  its  Intra-cranial  prolongation 
control  the  movements  of  respiration,  and  hence  It  is 
well  known  to  physiologists  as  the  **  respiratory  tract  " 
— so  also  the  lower  dorsal  and  lumbar  divisions  exercise 
an  influence  on  the  genito-urinary  apparatus,  and  are 
known  as  the  '' genlto-spinal."  But  is  has  been  reserved 
for  the  more  modern  researches  of  Budge  and  Waller, 
who  In   185 1    demonstrated  that  the  filaments  of  the 


CC^tP.MCATIXG    IXJURIKS.  22  T 

sympathetic  that  supply  the  eye  take  their  origin  from 
that  part  of  the  spinal  cord  which  is  contiguous  to  the 
origin  of  the  first  pair  of  dorsal  nerves,  and  that  the 
portion  of  the  spinal  axis  which  extends  from  the  fifth 
cervical  to  the  sixth  dorsal  vertebra,  and  according  to 
Brown-Sequard,  even  as  far  as  the  tenth  dorsal,  pos- 
sesses a  distinct  influence  on  the  organs  of  vision. 
Hence,  by  these  physiologists  it  has  been  termed  the 
'■^  cilio-spinal^'  and  by  Claude  Bernard  the  ^^  octdo-spinar' 
axis."^ 

It  has  been  determined,  as  the  result  of  numerous 
sxperiments  by  these  physiologists,  that  the  partial 
division  of  this  cilio-spinal  axis  occasions  various  dis- 
turbing influences  on  the  size  of  the  pupil,  the  vascu- 
larization of  the  conjnnetiva,  and  probably  of  the  deeper 
ocular  tissues,  and  on  the  state  of  the  blood-vessels  of 
/he  ear,  and  exactly  similar  to  those  that  are  occasioned 
by  the  section  of  the  cervical  sympathetic.  The  con- 
clusion that  must  necessarily  be  deduced  from  these 
observations  Is,  that  this  portion  of  the  spinal  cord — 
the  osulo-spinal  axis — includes  within  itself  both  vaso- 
motor and  oculo-pupillary  filaments  which  are  connected 
with  the  cervical  portion  of  the  sympathetic. 

Claude  Bernard  has  pointed  out  clearly  the  fact  that 
the  vasi-motor  and  the  oculo-pupillary  nerves  possess 
different  reflex  actions.  By  dividing  the  two  first  dorso- 
spinal  roots  he  finds  that  the  oculo-pupillar  phenomena 
are  produced  without  occasioning  the  vasi-motor  effects 
in  vascular  injection  and  increase  of  temperature. 
Whereas,  by  dividing  the  ascending  sympathetic  fila- 
ment between  the  second  and  third  rib,  the  vasi-motor 
phenomena  are  developed  in  the  head  without  any  influ- 
ence being  exerted  on  the  eye  through  the  medium  of 
the  oculo-pupillary  filament.  He  sums  up  his  observa- 
tions as  follows  :  "  The  vaso-motor  and  the  oculo-pupil- 
lary nerves  do  not  act  in  the  same  way.  Thus,  a  slight 
irritation  of  the  auricular  nerve  only  occasions  vascu- 
larization in  the  corresponding  side,  whilst  the  same 
irritation  produces  reflex  movements  in  both  eyes  at  the 


*Rondeau,  Affections  oculaires  rejlexes,  p.  22,  ei  seq. 


222  IMPAIRMENT   OF   VISION 

same  time.  The  reflex  vascular  actions  do  not  appear 
to  be  capable  of  being  produced  on  the  opposite  side  to 
that  which  is  irritated  (d'une  maniere  croisee),  and  besides 
this  they  are  limited  and  do  not  extend  beyond  a  cer- 
tain determined  line  of  circumscription.  All  this  is  in 
striking  contrast  with  the  oculo-pupillary  actions  which 
are,  on  the  contrary,  general  and  crossed." — Rondeau, 
op.  cit.  p.  24. 

These  physiological  observations  have  an  important 
practical  bearing  on  affections  of  the  eye  and  loss  of 
vision  consequent  on  injuries  of  the  spine. 

Clinical  observations  support  the  result  of  physio- 
logical experiment  in  the  connection  that  subsists 
between  the  oculo-spinal  axis  of  the  cord  and  the  integ- 
rity of  vision.  Thus — without  going  so  far  back  as  the 
account  that  Plutarch  gives  of  the  injury  sustained  by 
Alexander  the  Great,  who  was  in  danger  of  losing  his 
sight  from  the  effect  of  a  blow  inflicted  by  a  heavy 
stone  on  the  back  of  the  neck — the  records  of  surgery 
contain  numerous  illustrations  of  the  injurious  influence 
of  blows  on  the  sight — of  blows  inflicted  on  the  lower 
cervical  and  upper  dorsal  spine.  Thus  Rondeau  relates 
that  he  saw  the  following  case  at  an  asylum  for  the 
blind:  A  lad,  aged  17,  fell,  when  5  years  of  age,  down 
a  staircase,  striking  the  shoulders  and  the  back  of  the 
neck  against  the  edge  of  the  steps.  He  did  not  lose 
consciousness,  but  some  days  afterwards  he  became 
quite  blind.  Under  treatment,  his  sight  gradually 
returned,  so  that  at  the  end  of  a  month  he  could  distin- 
guish the  light,  and  in  the  course  of  four  years  he 
could  discern  objects  placed  near  to  him.  Beyond  this 
no  improvement  took  place,  and  when  Rondeau  saw 
him  he  found  the  pupils  dilated  and  the  optic  disc  in  a 
state  of  white  atrophy,  more  marked  towards  the  centre 
than  at  the  circumference. 

The  influence  on  vision  of  blows  and  injuries  of 
that  part  of  the  spine  situated  at  the  root  of  the  neck 
and  between  the  shoulders,  is  well  illustrated  by  many 
of  the  cases  narrated  in  this  work,  and  explains  the 
statement  made  by  Dr.  Allbutt,  of  Leeds,  in  his  inter- 
esting and  important  observations  to  which  reference 


COMPLICATING   INJURIES.  223 

has  already  been  made,  that  those  injuries  and  con- 
cussions of  the  spine  that  occur  high  up  are  more 
injurious  to  vision  than  such  as  are  inflicted  on  the 
lower  portion  of  the  vertebral  column. 

To  what  is  this  impairment  of  vision  due?  Dr.  All- 
butt,  who  has  studied  the  subject  with  much  care,  gives 
his  opinion,  in  which  I  fully  coincide,  so  clearly  that  I 
cannot  do  better  than  to  quote  his  own  words : — ''  In 
default  of  a  series  of  autopsies,  we  seem  to  be  led 
towards  the  conjecture  that  hyperaemia  of  the  back  of 
the  eye,  followi-ng  injury  to  the  spine,  is  probably 
dependent  upon  a  greater  or  less  extension  of  the 
meningeal  irritation  up  to  the  base  of  the  brain.  Now, 
have  we  any  reason  to  suppose  that  spinal  meningitis 
does  creep  up  into  the  encephalon  ?  We  have :  for, 
setting  aside  the  curious  head  symptoms  such  patients 
often  present,  here  the  actual  demonstration  of  autopsy 
comes  to  aid  us.  It  is  tolerably  well  known  to  careful 
pathologists  that  encephalic  meningitis  is  a  very  com- 
mon accompaniment  of  spinal  meningitis.  It  is  scarcely 
needful  to  point  out  that  if  this  explanation  of  an 
ascending  meningitis  be  the  correct  one,  it  accords  with 
my  observation,  stated  above,  that,  in  general,  the 
higher  the  injury  to  the  spine  the  sooner  the  affection 
of  the  eye." 

In  chronic  spinal  meningitis,  more  especially  in  the 
upper  parts,  there  may  be  found  a  hyperaemic  state  of 
the  fundus,  due  to  the  extension  upwards  and  along 
the  base  of  the  brain  of  the  inflammation  of  the  menin- 
ges. "  These  optic  lesions,"  says  Dr.  Long  Fox,  "  are 
due  solely  to  the  creeping  upwards  of  a  meningitis  that 
was  originally  spinal,  but  ends  in  being  cerebral." — 
Path.  Anat.  of  Nervous  System,  p.  398. 

4- — Impairment  of  Vision  from  Affection  of  the  Sym- 
pathetic.— Mr. Wharton  Jones, ^  who  has  investigated  the 
,  influence  of  the  sympathetic  in  a  truly  philosophic 
spirit,  states  that  an  affection  of  the  sight  in  the  form 
of  perverted,  impaired,  or  lost  sensibility  of  the  optic 

*  J'ailtire  of  Sii.^ht  from  Railivay  and  other  Injuries  of  the  Spine  and 
Head:  1869;  a  most  al)le  and  philosophic  work, 


224  IMPAIRMENT   OF   VISION 

nervous  apparatus,  is  liable  to  supervene,  in  a  longer  or 
shorter  time,  on  concussion  of  the  spinal  cord  or  brain. 
The  symptoms,  as  a  rule,  come  on  insidiously,  and  do 
not  attain  any  degree  of  prominence  until  a  considera- 
ble time  after  the  accident — may  be  many  months.  At 
first  they  are  transitory  and  subjective  in  character,  and 
consist  of  asthenopia,  luminous  spectra,  rings,  stars,  and 
flashes  of  light,  scotomata,  photophobia,  impaired 
power  of  adjustment,  undue  retention  of  images,  fail- 
ure of  power  to  estimate  distance  and  position  (and  to 
co-ordinate  voluntary  movem.ents),  diplopia.  The  size 
of  pupil  varies,  it  may  be  in  the  middle  state,  or  con- 
tracted, or  more  rarely  dilated,  and  its  action  may  be 
sluggish  or  unduly  active.  After  these  transitory  symp- 
toms have  existed  for  some  time,  the  vision  gradually 
deteriorates  and  finally  becomes  amaurotic.  The  oph- 
thalmoscopic appearances  that  are  to  be  observed  in 
eyes  that  are  undergoing  the  changes  which  eventuate 
in  blindness,  are,  according  to  Mr.  Jones,  in  the  early 
stages,  "  increased  vascularity  with  some  whiteness  of 
the  optic  disc  ;  congestion  of  the  retina  ;  blackish  dis- 
coloration of  the  retina  adjacent  to  the  disc  ;  pigmeh- 
tous  deposit  in  the  disc  itself."  Ultim.ately,  the  optic 
nerve  becomes  atrophic  and  white.  In  some  cases, 
however,  of  failing  sight  after  injuries  to  the  spine  or 
head,  no  ophthalmoscopic  evidence  may  declare  itself 
for  a  considerable  time.*  If  the  injury  be  inflicted  on 
some  part  of  the  "  optic  nervous  apparatus  "  behind  the 
eye,  as,  for  instance,  in  the  corpora  quadrigemina,  the 
tractus  optici,  the  commissure  or  orbital  part  of  the 
optic  nerve,  the  sight  may  be  greatly  impaired  or  actu- 
ally destroyed  long  before  there  are  any  appreciable 
ophthalmoscopic  manifestations  of  the  morbid  changes. 
Atrophy  of  the  optic  nerve  is  generally  the  final  stage, 
but  that  form  of  atrophy  which  supervenes  on  spinal 
injury  is  a  result  of  optic  neuritis,  and  does  not  attaia 
so  complete  development  as  the  white  atrophy  of  cere- 
bral amaurosis. 

The  amaurotic  affections  depend  on  nutritive  changes, 
as  congestion,  hyperaemia,  anaemia,  inflammation,  and 
its  consequences,  leading  to  degeneration   of  structure 


COMPLICATING  INJURIES.  225 

and  nervous  exhaustion  in  some  portion  of  the  optic 
nervous  apparatus.  If  the  seat  of  the  morbid  pro- 
cesses be  in  the  retina,  impressions  are  not  received,  if 
in  the  optic  nerve  or  tract  they  are  not  transmitted,  and 
if  in  that  part  of  the  brain  with  which  the  optic  nerve 
is  connected,  the  sensorial  power  to  take  cognizance  of 
the  transmitted  impressions  is  lost.  But  whatever  part 
sustains  the  primary  injury,  the  ultimate  result  is  the 
same  ;  the  affection  of  one  part  leads  to  the  degenera- 
tion of  the  whole,  and  white  atrophy  of  the  optic  disc 
and  atrophy  of  the  intra-cranial  portion  of  the  optic 
nervous  apparatus  ensue. 

To  explain  and  account  for  the  changes,  Mr.  Wharton 
Jones  has  brought  together  a  large  amount  of  physio- 
logical knowledge,  and  arguing  from  the  experimental 
and  pathological  evidence  of  the  influence  which  the 
sympathetic  nerves  exert  on  the  arterial  system,  has 
inferred  that  the  failure  of  sight  after  injury  to  the  spinal 
cord,  where  the  brain  is  apparently  unaffected,  is  due  to 
the  transmission  of  the  morbid  action  from  the  cord  to 
the  bloodvessels  of  the  optic  nervous  apparatus  by  the 
sympathetic  nerves  rather  than  to  the  extension  of  the 
inflammatory  and  degenerative  changes  from  the  spinal 
cord  to  the  brain.  In  support  of  this  position  Mr.  Jones 
describes  in  detail  the  experimental  effects  on  the  nutri- 
tion of  certain  areas  produced  by  irritation  or  section 
of  the  sympathetic  nerves  supplying  the  bloodvessels  of 
these  parts  ;  and  compares  the  effects  of  spinal  injury  on 
the  sight  with  those  of  locomotor  ataxy.  He,  more- 
over, enters  into  a  minute  description  of  the  origin  and 
distribution  of  the  sympathetic  nerves,  supplying  the 
bloodvessels  which  go  to  supply  the  brain  and  the 
organs  of  sight  and  hearing.  He  points  out  that  the 
sympathetic  nerve  of  the  neck  was  first  shown  by  Dr. 
Brown-Sequard'^  to  have  its  roots  in  that  part  of  the 
spinal  cord  which  extends  from  the  sixth  cervical  to  the 
ninth  or  tenth  dorsal  vertebra.     Then  Wutzerf  stated 


*   Sur  les  Resultats  de  la  Section  et  de  la  Gahmjiisation  du  Ne7-f  Grand 
Sympathetic  au   Cou.      In  Gazette  Medicale  de  Paris,  1854. 
f  Muller's  Archiv.  1834,  [>.  306. 

15 


226  IMPAIRMENT   OF   VISION 

that  the  sympathetic  derives  radicle  fibres  from  both 
roots  of  the  spinal  nerves,  while  Mayer*  traced  these 
fibres  in  the  roots  to  the  spinal  cord  itself.  Arguing 
from  Professor  Budge'sf  experiments,  it  is  affirmed  that 
of  these  fibrils  some  of  them  are  centrifugal  or  motor, 
and  pass  through  the  anterior  roots,  while  some  are 
centripetal  or  excitor,  and  pass  through  the  posterior 
roots  to  the  ganglion  cells,  which  lie  near  the  centre  of 
the  grey  substance  of  the  cord,  between  the  cells  of  the 
anterior  roots  and  the  cells  of  the  posterior  roots. 
From  this  origin  the  fibrils  pass  through  rami-commu- 
nicantes  of  the  corresponding  spinal  nerves  to  join  the 
sympathetic  in  the  neck,  and  thence  to  enter  the 
cranium  in  the  internal  carotid  and  vertebral  plexus. 
The  exact  distribution  of  the  nerve  is  as  follows ;  Some 
of  the  anterior  branches  of  the  superior  cervical  gang- 
lion form  the  external  carotid  plexus;  the  internal  caro- 
tid plexus  is  formed  by  the  ascending  branches  of  the 
superior  cervical  ganglion,  v/hich  gives  off  filaments  to 
the  walls  of  the  branches  of  this  artery,  and  among 
others,  to  the  ophthalmic  artery.  From  this  plexus, 
also,  is  derived  a  filament  which  joins  the  ophthalmic 
division  of  the  fifth  nerve  in  the  cavernous  sinus,  and 
then  enters  the  orbit.  Ths  nasal  branch,  which  con- 
tains many  of  these  filaments,  gives  off  the  long  root 
of  the  lenticular  ganglion,  and  a  few  ciliary  nerves,  the 
majority  of  the  ciliary  nerves  being  derived  from  the 
lenticular  ganglion.  The  middle  root  of  the  ganglion 
is  also  a  filament  of  the  carotid  plexus,  while  the  short 
root  is  derived  from  the  lower  branch  of  the  oculo- 
motor nerve.  The  ciliary  nerves  then  accompany  the 
ciliary  arteries  into  the  eyeball,  and  the  arteria  centralis 
retinae  is  accompanied  by  a  minute  branch  from  the 
lenticular  ganglion.  The  fibrils  of  the  oculo-motor 
nerve  which  the  ciliar}^  nerves  derive  from  the  short 
root  of  the  ganglion  govern  the  contractions  of  the 
muscular  fibres  of  the  sphincter  pupillse,  while  the 
sympathetic  fibrils  govern  the  contraction  of  the  mus- 

*  Nova  Acta,  xvi.  p.  2. 

f  Ueber  die  Bewegung  der  Iris  Fur  Physiologen  und  Aerzte,   Braunsch- 
weig, 1855. 


COMPLICATING   INJURIES.  22/ 

cular  walls  of  the  arteries  and  of  the  radiating  fibres  of 
the  dilator  pupillae. 

By  the  aid  of  this  knowledge  of  the  distribution  of 
the  sympathetic  of  the  neck,  the  phenomena  of  irrita- 
tion or  division  of  the  nerve  may,  Mr.  Jones  affirms,  be 
explained.  Experiments  have  shown  that  division  of 
the  sympathetic  nerve  in  the  neck  is  followed  by  heat 
and  vascular  fulness  in  the  corresponding  side  of  the 
head  ;  the  ear  becomes  dark-red ;  the  conjunctiva  and 
nasal  mucous  membrane  turgidly  injected,  and  the 
pupil  contracted.  The  same  effects  follow  when  the 
spinal  cord  is  experimented  on  between  the  sixth  cer- 
vical and  the  ninth  or  tenth  dorsal  vertebra. 

On  the  other  hand,  irritation  of  the  sympathetic 
nerve  above  the  section  of  that  portion  of  the  spinal 
cord  just  referred  to,  produces  coldness  and  a  pallor  of 
those,  parts,  by  constricting  the  arteries,  and  dilata- 
tion of  the  pupil.  The  alterations  in  the  size  of  the 
arteries  are  associated  with  corresponding  changes  in  the 
nutrition  and  vital  energy  of  the  affected  part.  When 
the  vessels  are  constricted  through  irritation  of  the 
sympathetic  nerve,  the  circulation  is  retarded,  the  nutri- 
tion impaired,  the  heat  lessened,  and  the  vital  energy 
dimxinished.  Whereas,  destruction  of  the  sympathetic 
is  followed  by  dilatation  of  the  arteries,  and  a  fuller 
and  free  flow  of  blood  through  them  ;  and  in  some  cases 
actual  inflammation  may  result.  When  the  sympa- 
thetic nerve  in  the  neck  or  the  spinal  cord,  lying 
between  the  sixth  cervical  and  tenth  dorsal  vertebrae,  is 
morbidly  affected,  nutritive  changes,  with  correspond- 
ing symptoms,  declare  themselves.  When,  for  instance, 
the  sympathetic  in  the  neck  is  irritated  as  a  result  of 
disease  or  injury  of  the  spinal  cord,  the  arteries  sup- 
plying the  optic  nervous  apparatus  are  constricted,  and 
there  is  temporary  impairment  of  vision.  But  when 
the  nerve  is  destroyed,  the  early  symptoms  are  usually 
photophobia,  photopsia,  &c.  By  and  by  th&se  transient 
changes  in  the  circulation  of  the  optic  nervous  appa- 
ratus becomes  persistent,  and  a  low  form  of  inflam- 
mation results.  Other  observers  have  explained  the 
pathology  of  this  inflammation  in   a  different  manner. 


228  IMPAIRMENT   OF  VISION 

According  to  some,  the  inflammation  starts  in  the  cen- 
tral portion  of  the  optic  nerve,  and  is  directly  trans- 
mitted along  the  nerve ;  or  the  intra-cranial  mischief 
may  manifest  itself  through  the  disturbed  circulation 
in  the  retinal  vessels  within  the  eye,  under  the  form  of 
venous  congestion  and  swelling  of  the  optic  disc.  But 
Mr.  Jones  maintains  that  there  are  instances  in  which 
hyperaemia,  congestion,  and  even  actual  inflammation 
of  the  optic  nerve  occur  without  there  being  any  evi- 
dence of  intra-cranial  disease.  Von  Graefe,  as  is  well 
known,  believed  that  the  venous  congestion  of  the  optic 
dise  was  the  result  of  the  incarcerating  action  of  the 
sclerotic  ring,  while  Dr.  Clifford  Allbutt  supposed  that 
pressure  on  the  cavernous  sinus  acted  as  an  auxiliary 
by  preventing  the  return  of  venous  blood  from  the  eye. 
But  Mr.  Jones  thinks  that  the  contraction  of  the 
arteries,  and  the  accumulation  and  stagnation  of  the 
blood  in  the  capillaries  and  venous  radicles,  may  be 
accounted  for  by  irritation  of  the  sympathetic  nerve  in 
the  neck,  or  by  irritation  of  the  spinal  cord  in  the  cer- 
vico-dorsal  region.  When  the  sympathetic  in  the  neck, 
or  the  cervico-dorsal  portion  of  the  spinal  cord  is 
irritated,  in  addition  to  the  changes  in  the  circulation 
of  blood  in  the  optic  nervous  apparatus,  the  pupil 
becomes  more  or  less  dilated  ;  but  when  the  nerve  is 
actually  destroyed,  the  pupil  is  contracted. 

When  the  head  itself  has  been  injured,  amaurosis 
may,  according  to  Mr.  Jones,  follow  as  a  result  of  actual 
injury  to  the  optic  nervous  apparatus,  of  the  pressure  of 
extravasated  blood,  or,  thirdly,  of  inflammation  of  the 
optic  nerve,  as  a  sequence  of  basilar  meningitis.  Here 
again  failure  of  sight  may  precede  any  ophthalmoscopic 
evidence. 


LECTURE  XL 

ON  CERTAIN  FORMS  OF  PARALYSIS  OF  THE  LIMBS 
FROM  LOCAL  INJURIES  WHICH  MAY  COMPLICATE 
CONCUSSION   OF  THE   SPINE. 

Wounds  of  nerves,  incised  or  gunshot,  necessarily  lead 
to  the  paralysis  of  the  parts  supplied  by  the  injured 
trunk.  The  consideration  of  such  injuries  is  altogether 
foreign  to  this  work,  and  you  will  find  it  treated  in  an 
exhaustive  manner  by  Dr.  Mitchell,  of  Philadelphia,  in 
a  special  treatise  on  this  subject." 

There  are,  however,  lesions  of  nerves  of  a  somewhat 
obscure  character,  arising  from  their  compression,  con- 
cussion, or  strain,  to  which  I  may  briefly  direct  your 
attention,  as  coming  within  the  scope  of  these  Lectures. 

The  nerves  are  less  frequently  injured  by  accidents 
affecting  the  limbs  than  would  at  first  appear  probable. 
This  is  in  great  measure  owing  to  their  escaping  ordi- 
nary blows  and  strains  by  being  situated  on  the  most 
protected  side  of  the  limb,  and  by  the  tendency  they 
have,  in  consequence  of  the  laxity  of  their  connections, 
to  fall  away  from  the  part  struck,  and  thus  to  escape 
injury. 

When  compressed  or  concussed,  the  immediate  symp- 
toms consist  of  tinglings  and  numbness  along  the 
courses  of  the  nerve,  usually  of  a  transitory  character. 
If  the  pressure  is  more  continuous,  it  becomes  a  common 
cause  of  temporary  paralysis.  A  familiar  illustration 
of  this  is  afforded  by  the  partial  paralysis,  both  of 
sensation  and  motion,  that  often  affects  the  hands  of 
persons  who  lean  long  and  heavily  on  crutches,  and  by 
that  means  compress  the  axillary  plexus. 

The  same  kind  of  paralysis  may  occur  in  some  forms 
of  spinal  injury,  especially  in  strains  of  the  vertebral 
column,  in  consequence  of  which  the  nerve-trunks 
become  compressed  near  their  origins,  or  as  they  escape 

*  "  Injuries  of  Nerves  and  their  C'onsequences,"  by  J.  Weir  Mitchell 
M.D.,  Philadelphia,  1872. 


230  VARIETIES  OF  PARALYSIS 

through  the  foramina,  by  effusions,  whether  of  blood 
or  inflammatory  exudations. 

The  nerves  that  are  most  frequently  injured  by  these 
concussions,  contusions,  or  compressions  are  the  sciatic 
and  its  branches  in  the  lower,  and  the  circumflex, 
ulnar,  and  musculo-spiral  in  the  upper  extremities.  I 
have  so  frequently  spoken  in  these  Lectures  of  the 
various  forms  of  paralysis  of  the  lower  extremities 
resulting  from  injury  to  the  nerves  of  the  lumbo-sacral 
plexus  generally,  and  more  especially  to  the  sciatic, 
that  I  need  say  nothing  about  them  here.  But  I  shall 
confine  myself  to  the  consideration  of  certain  forms  of 
paralysis  of  the  upper  extremities,  which  arise  from 
injury  to  special  nerves  of  the  brachial  plexus,  either 
from  injury  of  the  cord  in  the  cervical  region,  or  of  the 
nerve-trunks  themselves  in  their  course  down  the  limb. 
The  supra-scapular,  the  circumflex,  and  the  musculo- 
spiral  nerves  are  those  that  are  most  liable  to 
injury. 

The  supra-scapular  nerve  may  be  injured  by  direct 
violence  applied  to  the  back  of  the  scapula.  A  most 
marked  instance  of  this  form  of  injury,  leading  to  para- 
lysis and  acute  atrophy  of  the  supra  and  infra-spinatus 
muscles,  occurred  in  the  case  of  a  young  man  who  came 
under  my  care  at  University  College  Hospital  for  an 
injury  of  the  right  shoulder,  occasioned,  he  said,  by  the 
running  away  of  a  horse  which  he  was  driving.  In  order 
to  pull  it  in  he  twisted  the  rein  round  his  right  hand, 
but  the  horse  overpowering  him,  he  felt  acute  pain  in 
the  shoulder,  which  gradually  became  powerless.  On 
examination,  the  supra  and  infra-spinatus  muscles  were 
found  to  be  completely  atrophied,  so  as  to  leave  deep 
hollows  above  and  below  the  spine  of  the  scapula.  The 
atrophied  remains,  if,  indeed,  any  existed,  of  the  muscles 
were  insusceptible  to  the  electric  current,  and  the 
deltoid  was  partially  wasted.  In  this  case  it  would 
appear  that  the  supra-scapular  nerve  had  been  over- 
strained— had  become  paralysed,  and  that  acute  atrophy 
of  the  muscles  supplied  by  it  had  ensued. 

Paralysis  of  the  deltoid  from  injury  to  the  circumflex 
nerve  of  the  arm  is  by   no  means    uncommon.     This 


FROM   LOCAL  INJURIES.  23  I 

condition  usually  happens  from  falls  on  the  shoulder, 
and  direct  concussion  of  the  nerve.  In  it  the  deltoid 
gradually  wastes,  so  that  the  acromion  becomes  promi- 
nent. In  consequence  of  this  atrophy,  the  arm  cannot 
be  raised  from  the  side,  or,  if  raised,  it  cannot  be  main- 
tained in  the  extended  position.  The  natural  support 
of  the  arm  by  one  of  its  capsular  muscles  being  lost, 
the  shoulder  not  only  loses  its  rotundity,  in  consequence 
of  the  loss  of  power  in  the  deltoid,  but  the  arm  drops, 
and  then  the  withered  deltoid  becomes  drawn  down, 
and  thus  the  flattening  of  the  shoulder  is  increased. 
The  acromion  appears  to  project ;  a  hollow,  into  which 
the  tips  of  the  fingers  ean  be  insinuated,  is  formed 
under  it,  and  the  head  of  the  bone  is  drawn  somewhat 
forwards  by  the  action  of  the  pectoralis  major.  Thus, 
there  is  produced  a  remarkable  simulation  of  a  partial 
dislocation  of  the  head  of  the  bone  inwards,  and,  indeed, 
some  secondary  displacement  often  occurs  in  this  direc- 
tion, which  requires  to  be  corrected  under  chloroform 
before  faradisation  and  general  tonic  treatment,  with  the 
view  of  restoring  power  to  the  nerves  and  tone  to  the 
muscles,  can  be  employed  with  success. 

The  musculo-spiral  is  the  nerve  the  paralysis  of 
which  leads  to  the  most  serious  consequences.  This 
condition  may  arise  from  injury  to  the  cervical  spine,  or 
to  the  trunk  of  the  nerve. 

In  Case  31  you  will  find  an  instance  of  its  paralysis 
from  spinal  injury.  I  will  now  relate  several  cases  of  a 
previously  undescribed  form  of  paralysis  from  fractures 
of  the  humerus,^ 

Simple  fractures  of  the  long  bones  are  seldom  accom- 
panied by  any  serious  complications ;  the  vessels  and 
nerves  of  the  limbs  being  so  situated,  and  being  so 
well  protected  by  the  interposition  of  a  layer  of  muscle 
between  them  and  the  bones,  as  to  escape  being  injured, 
in  the  vast  majority  of  cases,  by  the  ends  of  the  frac- 
tured fragments.  There  are,  however,  two  exceptions 
to  this  general  rule :  one  in  the  upper,  the  other  in  the 
lower,  extremity.  In  the  upper  extremity,  in  the  relation 

'''Lancet,  July  i,  1871. 


232  VARIETIES   OF   PARALYSIS 

of  the  musculo-spiral  nerve  to  the  shaft  of  the  humerus  ; 
in  the  lower,  in  the  position  of  the  posterior  tibial 
artery  in  reference  to  the  upper  end  of  the  tibia.  In 
both  these  instances  the  position  of  the  nerve  and  of 
the  vessel  is  such  that  they  may  be  seriously  injured  by 
fracture  of  the  contiguous  long  bones. 

The  complication  of  an  injury  of  the  musculo-spiral 
nerve,  in  a  case  of  simple  fracture  of  the  humerus, 
must  certainly  be  of  rare  occurrence,  as  I  find  no  men- 
tion made  of  it  in  the  standard  works  on  surgery  that 
I  have  had  an  opportunity  of  consulting,  and  I  do  not 
recollect  to  have  met  with  this  accident  until  recently. 
I  have,  however,  had  lately  three  cases  under  my  care 
at  the  hospital,  in  which,  in  consequence  of  injury  to 
the  musculo-spiral  nerve,  or  one  of  its  branches,  more  or 
less  complete  paralysis  of  the  muscles  supplied  by  that 
nerve  resulted.  These  cases  I  will  presently  relate  to 
you,  and  on  them  I  will  found  the  observations  I  have 
to  make  on  this  interesting  subject. 

When  we  observe  the  manner  in  which  the  musculo- 
spiral  nerve  winds  closely  round  the  back  of  the  shaft 
of  the  humerus  in  its  flattened  groove,  and  how  in  its 
course  downwards  towards  the  forearm  it  comes  into 
tolerably  close  relations  to  the  outer  condyle,  we  can 
easily  understand  how  in  fractures  of  the  shaft  of  the 
bone  the  main  trunk  may  be  implicated,  and  in  those 
of  the  condyle  one  or  other  of  its  chief  divisions 
injured. 

When  the  main  trunk  of  the  musculo-spiral  nerve 
is  injured  to  such  an  extent  as  to  induce  complete 
paralysis  of  it,  both  the  supinators  of  the  forearm  and 
all  the  extensors  of  the  wrist  and  fingers  lose  their 
power,  and  the  patient  becomes  utterly  incapable  of 
performing  those  movements  that  are  dependent  on 
the  action  of  these  muscles.  The  hand  consequently 
falls  into  a  state  of  pronation  and  flexion,  presenting 
the  characteristic  signs  of  *' wrist-drop." 

When  the  posterior  interosseous  division  of  the  m.us- 
culo-spiral  is  the  nerve  that  is  injured,  the  loss  ot 
supination  and  of  extension  is  not  so  complete.  The 
supinator  longus  and   extensor    carpi    radialis   longior 


FROM    LOCAL   L\' JURIES.  233 

muscles,  being  supplied  by  branches  from  the  main 
trunk,  are  not  paralysed,  and  thus  a  certain  though 
very  limited  movement  or  supination  and  extension  is 
preserved,  although  the  forearm  and  hand  fall  naturally 
into  a  state  of  pronation  and  flexion. 

These  different  conditions  were  well  illustrated  in 
the  following  three  cases,  which  I  will  relate  to  you  in 
the  order  of  their  degrees  of  extent  and  severity,  so  far 
as  regards  the  paralysis  of  the  various  sets  of  muscles. 
An  attentive  study  of  the  movements  of  the  wrist, 
hand  and  fingers  in  these  cases  throws  a  clear  light  on 
the  actions  of  the  muscles  supplied  by  the  musculo- 
spiral  nerve  and  its  branches,  and  some  of  the  other 
nerves  of  the  forearm  and  hand. 

Case  ^\.—FracUtre  of  Shaft  of  Humerus— Paralysis 
of  Trunk  of  Musado-spiral  Nerve,  and  complete  Loss  of 
Extension  of  the  Wrist,  Fingers,  and  Thumb— Loss, 
nearly  complete,  of  Supination.— ^,  L.,  aged  29,  by  occu- 
pation an  ironer,  admitted  December  16,  1870.  Ten 
weeks  before  the  patient  fell  and  fractured  her  humerus 
about  the  middle.  She  was  treated  as  an  out-patient 
and  the  limb  put  upon  an  angular  splint,  so  as  to  fix 
the  elbow-joint.  When  the  splint  was  left  off,  at  the 
end  of  four  weeks,  she  was  directed  not  to  use  her  arm 
for  a  week.  She  noticed  wrist-drop  when  she  took  off 
the  splint,  but  thought  it  was  mere  weakness.  At  the 
end  of  a  week,  however,  on  trying  to  use  her  hand,  she 
found  that  she  had  no  power  in  the  wrist  or  fingers. 
It  was  thought  to  be  weakness,  and  she  bathed  it  with 
cold  water.  The  hand  had  for  some  time  felt  much 
colder  than  the  other.  On  examination  it  was  found 
that  there  was  marked  wrist-drop,  with  pronation.  She 
could  not  extend  the  hand  at  all.  The  right  forearm, 
hand,  and  fingers  were  swollen.  She  felt  a  difference 
in  the  temperature  of  the  two  hands,  but  not  so  great 
as  formerly.  Occasionally  she  had  a  feeling  of  pins  and 
needles  all  down  the  hand  and  fingers.  The  thumb 
and  index  finger,  especially  the  former,  were  numb  on 
the  dorsal  aspect.  Sensation  over  them  was  imperfect. 
Flexion  of  the  fingers  was  imperfect,  owing  to  stiffness 
of  the  knuckles.    The  temperature  of  the  affected  hand 


234  VARIETIES   OF   PARALYSIS 

did  not  raise  the  index  of  the  clinical  thermometer  to 
85'' ;  that  of  the  other  was  90.6°.  All  the  muscles  sup- 
plied by  the  musculo-spiral  nerve  were  paralyzed  com- 
pletely. She  had  consequently  totally  lost  all  power 
of  extending  the  wrist.  She  had  no  power  of  extending 
the  thumb.  She  had  no  power  of  extending  the  fingers 
from  the  meta-carpo-phalangeal  joints ;  but  when  the 
fingers  were  completely  flexed  she  could  extend  the 
joints  between  the  first  and  second  and  second  and 
third  phalanges.  This  was  evidently  accomplished  by 
means  of  the  interossei  and  lumbricales  muscles,  which 
are  attached  to  the  expansion  of  the  extensor  tendons 
on  the  dorsum  of  the  fingers  lower  down  than  the 
metacarpo-phalangeal  joints.  On  holding  the  index 
finger  forcibly  down,  and  telling  her  to  try  to  extend  it, 
the  thumb  was  drawn  in  towards  the  palm  by  the 
attachment  of  the  first  dorsal  interosseous  to  the  met- 
carpal  bone  of  the  thumb.  Supination  could  be  per- 
formed apparently  in  a  very  feeble  and  imperfect  man- 
ner, but  only  when  the  forearm  was  flexed.  Flexion 
of  wrist,  hand,  and  fingers  was  perfect. 

After  this  she  was  galvanized  by  faradization  regu- 
larly, and  regained  considerable  power  in  all  the  affected 
muscles,  so  that  she  could  extend  the  wrist  and  the 
fingers  from  their  metacarpo-phalangeal  articulations. 

There  are  several  points  in  this  case  that  deserve 
special  attention.  That  the  trunk  of  the  musculo-spiral 
nerve  was  paralyzed  by  being  implicated  in  the  fracture 
which  occurred  in  that  part  of  the  humerus  round 
which  it  winds,  there  can  be  no  doubt.  All  the  muscles 
connected  with  the  hand  and  wrist  that  are  supplied  by 
both  the  terminal  divisions  of  that  nerve — the  radial 
and  the  posterior  interosseous — were  paralyzed,  and 
none  other  were  affected. 

Now  let  us  examine  a  little  more  in  detail  the  con- 
ditions of  the  hand  and  fingers.  The  wrist-joint  was 
flexed,  so  that  the  hand  hung  listless  and  inactive,  at 
nearly  right  angles  with  the  forearm.  It  could  not  be 
raised  or  extended  in  the  slightest  degree.  No  effort 
that  the  patient  made  in  this  direction  was  of  any  avail. 
There  was,  consequently,  complete  paralysis  of  the  two 


COMPLICATING   IN7URV.  235 

extensors  of  the  wrist — the  long  and  the  short.  The 
hand  was  prone  ;  complete  supination  was  impossible, 
and  no  movement  whatever  in  that  direction  could  take 
place  when  the  forearm  was  extended  on  the  arm.  But 
when  the  forearm  was  flexed,  a  slight  supine  movement 
could  be  made  by  the  patient.  To  what  was  this  due? 
Clearly  not  to  the  supinators,  which  would  have  acted 
equally  well  whatever  the  position  of  the  elbow  might 
have  been.  But  apparently  the  slight  effort  at  supina- 
tion— for  it  was  really  nothing  more — was  the  result  of 
contraction  of  the  biceps,  which,  as  you  are  aware, 
when  called  into  action  whilst  the  hand  is  prone,  has 
for  its  first  effect  a  tendency  to  supinate  the  forearm 
and  hand.  There  was,  consequently,  complete  paralysis 
of  the  two  true  supinators — the  long  and  the  short* 
Thus  there  must  have  been  loss  of  innervation  in  both 
the  terminal  branches  of  the  muscu-lo-spiral — the  radial 
and  the  posterior  interosseous.  The  long  extensor  of 
the  fingers  was  paralyzed,  so  that  they  hung  at  right 
angles  with  the  hand ;  they  could  not  possibly  be 
extended  from  the  metacarpo-phalangeal  articulations 
so  as  to  be  brought  to  a  level  with  the  dorsum  of  the 
hand.  But  there  was  one  movement  of  extension  still 
left  to  the  fingers,  and  it  was  this :  that  when  they 
were  bent  or  drawn  into  the  palm  of  the  hand,  the  last 
two  phalanges  could  be  extended,  and  with  some  little 
force,  from  the  articulations  between  the  first  and  sec- 
ond phalanges.  Now  this  is  an  extremely  interesting 
point,  and  one  to  which  I  would  direct  your  close  atten- 
tion. To  what  is  this  upward  or  extending  movement 
of  the  two  terminal  phalanges  due? — a  movement  that 
takes  place  independently  of  the  action  of  the  true 
extensors  of  the  fingers.  It  is  due  to  the  combined 
action  of  the  interossei  and  lumbricales — muscles  that 
do  not  receive  their  innervation  from  the  mxusculo- 
spiral,  but  chiefly  from  the  deep  branch  of  the  ulnar; 
all  the  interossei  and  the  two  innermost  lumbricales 
receiving  their  nerves  from  this  source,  whilst  the  two 
outermost  of  the  lumbricales  obtain  theirs  from  the 
median  nerve.  Thus  these  accessory  muscles  of  exten- 
sion, receiving  their  nervous  supply  from  sources  that 


236  VARIETIES   OF   PARALYSIS 

were  uninjured,  continued  in  the  free  exercise  of  their 
special  ations.  The  thumb  was  drawn  in  towards  the 
palm,  and  could  not  be  abducted  owing  to  the  paralysis 
of  the  extensor  muscle  of  the  metacarpal  bone.  The 
numbness  and  referred  sensations  occupied  those  por- 
tions of  integument  that  were  supplied  by  the  terminal 
branches  of  the  radial  nerve.  The  temperature  of  the 
hand  was  considerably  lower  than  the  other.  It  was 
below  the  lowest  mark  (85°  F.)  on  the  clinical  ther- 
mometer ;  and  as  that  of  the  sound  hand  was  90.6, 
there  must  have  been  a  difference  of  at  least  5°  to  6s 
F.  between  the  two  limbs. 

The  next  case  that  I  will  relate  to  you  is  one  in 
which  the  paralysis  seems  to  have  been  limited  to  the 
posterior  interosseous  nerve.     It  is  as  follows : 

Case  52.  Wrist-drop  folloiving  Conipoiind  Fracture  of 
the  External  Condyle  of  the  Humerus — Paralysis  co7ifined 
to  the  muscles  supplied  by  the  posterior  interosseous  nerve. 
— H.  E.,  aged  30,  by  occupation  a  lace-cleaner,  on 
November  17,  1870,  slipped  down  on  her  right  elbow  on 
the  pavement,  and  afterwards  came  to  the  hospital.  On 
examining  the  elbow,  much  mobility  and  crepitus  were 
found,  and  a  fracture  of  both  condyles,  with  separation, 
could  be  clearly  made  out.  At  the  back  of  the  arm, 
about  an  inch  above  the  elbow,  was  a  wound  which 
would  take  the  tip  of  the  little  finger,  clean  cut  without 
bruising  of  the  edges,  apparently  done  by  protrusion 
of  the  bone  at  the  time  of  the  fall.  A  probe  could  pass 
in  different  directions  readily  among  the  tissues.  From 
Nov.  17  till  Dec.  21  the  limb  was  kept  on  an  angular 
splint  at  the  inner  side,  and  the  wound  treated  in  strict 
accordance  with  Lister's  rules  for  antiseptic  dressing. 
On  Nov.  24  (eighth  day)  there  was  much  swelling,  with 
some  redness  and  tension,  about  the  joint  and  upper 
half  of  the  forearm.  It  was  thought  that  fluctuation 
existed ;  and  an  incision,  about  three-quarters  of  an 
inch  long,  was  made  below  the  elbow.  Much  serous 
fluid  came,  but  no  pus.  Large  quantities  of  serous 
fluid  continued  to  come  from  the  wound  for  a  fortnight 
afterwards.  The  tension  rapidly  disappeared  ;  no  pus- 
was  at  any  time  observed.     Passive  motion  was  com- 


COMPLICATING   INJURY.  237 

menced  on  Dec.  21.  The  splint  was  left  off  on  Dec.  23. 
There  was  much  stiffness  of  the  joint.        ' 

Jan.  23d. — Patient  can  bend  the  elbow  to  an  angle  of 
45  degrees ;  can  straighten  it  to  about  a  right  angle  and 
a  half.  Can  close  the  hand  as  far  as  to  bring  the  tips 
of  the  fingers  to  about  an  inch  from  the  palm  ;  her  hand 
can  be  made  to  close  completely  without  much  diffi- 
culty. There  is  perfect  flexing  and  opposing  power  in 
the  thumb.  When  the  hand  and  forearm  are  supinated 
the  wrist  is  quite  straight.  Cannot  completely  straighten 
the  hand  at  the  metacarpo-phalangeal  joint.  Very 
slight  force  brings  these  joints  straight ;  but  she  cannot 
extend  the  fingers.  When  the  hand  and  forearm  are 
pronated  there  is  a  complete  drop  of  the  wrist.  Cannot 
raise  wrist  or  fingers.  Cannot  move  the  thumb  out- 
wards or  backwards  (through  loss  of  power  of  the 
extensor).  There  is  almost  perfect  power  of  supination 
when  the  elbow  is  fixed.  When  the  fingers  are  com- 
pletely fixed,  she  is  able  to  extend  the  joints  between 
the  second  and  third  and  first  and  second  phalanges,  by 
means  of  the  lumbricales  and  interossei.  When  doing 
so,  as  the  hand  is  very  thin,  the  interossei  can  be  seen 
working.  There  is  slight  numbness  on  the  back  of  the 
thumb  and  index-finger,  but  no  absolute  loss  of  sen- 
sation. 

Now  this  case  closely  resembled  the  last  in  all  respects, 
with  the  sole  exception  of  the  paralysis  of  the  hand 
and  arm  not  being  so  complete.  The  general  aspect  of 
the  limb  was  the  same.  The  pronation  and  flexion  of 
the  forearm  and  wrist  were  marked  ;  but  the  power  of 
supination  was  not  completely  lost — in  fact,  existed  to 
a  considerable  degree,  but  was  not  perfect.  So  also 
with  regard  to  extension  of  the  hand  from  the  wrist. 
The  knuckles  could  be  brought  up  nearly  to  their  pro- 
per level.  Now  this  imperfect  power  of  supination  and 
of  extension  of  the  hand  was  doubtless  due  to  the 
supinator  longus  and  extensor  carpi  radialis  longior — 
muscles  supplied  by  the  radial  nerve — retaining  their 
power,  and  thus  being  able  to  act ;  whilst  the  short  supin- 
ator and  the  short  extensor  of  the  wrist,  both  supplied 
by  the  posterior  interosseous  nerve,  were  completely 


238  VARIETIES    OF    PARALYSIS 

paralyzed.  Hence  the  imperfection  of  the  supination 
and  extension  that  existed.  There  was  further  proof 
of  the  fact  of  the  radial  nerve  having  continued  to  main- 
tain its  action  in  the  fact  that  sensation  was  not  lost  in 
its  terminal  cutaneous  branches.  The  temperature  of 
the  hand  also  had  not  fallen,  as  in  the  first  case. 

Case  53.  Fracture  of  Lower  Epiphysis  of  Humerus — 
Wrist-drop  from  Paralysis  of  Posterior  Interosseous  Nerve 
—  Tonic  Contraction  of  Flexors. — M.  M.,  aged  seven,  was 
admitted  as  an  out-patient  under  Mr.  Heath,  and  by 
him  transferred  to  me.  In  June,  1870,  she  fell  over  a 
croquet  hoop,  and  the  lower  part  of  the  right  humerus 
was  fractured.  The  arm  was  at  first  supposed  by  her 
friends  to  be  dislocated,  and  a  non-medical  gentleman 
who  was  present  pulled  violeiitly  at  it  for  some  time, 
but  as  he  did  no  good,  she  was  taken  to  a  medical  man. 
Splints  were  used  for  seven  weeks ;  they  reached  from 
the  tips  of  the  fingers,  which  were  kept  extended. 
When  the  splints  were  left  off  the  fingers  became  flexed 
at  once.  Her  parents  thought  they  were  more  so  than 
on  admission.  She  could  crochet  with  the  right  hand, 
and  could  wTite,  but  badly ;  she  had  been  learning  to 
write  with  the  left  hand  in  consequence.  She  had  very 
marked  wrist  drop ;  she  could,  however,  easily  extend 
her  wrist.  Her  hand  was  pronated,  and  could  only  be 
imperfectly  supinated.  The  fingers  were  flexed  and 
drawn  into  the  palm  of  the  hand.  On  the  wrist  being 
dropped,  the  last  two  phalanges  of  the  fingers  could  be 
imperfectly  extended  by  the  patient.  On  the  wrist 
being  straightened,  the  fingers  became  flexed,  and  could 
not  be  extended  actively  or  passively.  On  forcibly 
extending  the  fingers  and  wrist,  there  was  no  tension 
of  the  palmar  fascia,  but  there  was  great  tension  of  the 
flexor  tendons  above  the  wrist.  The  hand  was  congested 
and  cold.  The  arm  was  distinctly  smaller  than  the 
other.  The  temperature  of  the  right  palm  was  not  high 
enough  to  move  the  index  of  the  thermometer — so  that 
it  is  below  85°,  that  of  the  left  being  93.6°.  The  sensi- 
bility of  the  hands  were  tested  by  compasses ;  it  seemed 
quite  as  acute  in  the  right  as  the  left.  There  was  some 
irregularity  of  the  lower  end  of  the  outer  condyle,  which 


COMPLi(:ATIN(i    INJURY.  239 

seemed  to  have  been  the  situation  of  the  fracture,  or 
separation  of  the  epiphysis,  which  was  the  original 
injury. 

Dec.  19th. — I  ordered  a  spHnt  to  be  specially  con- 
structed, so  as  to  permit  of  gradual  extension  of  the 
fingers  by  means  of  a  movable  hand-piece  worked  by  a 
rack  and  pinion. 

Jan.  14th,  1 87 1. — I  ordered  her  arm  to  be  faradized 
daily.  There  was  at  first  scarely  any  contractility  per- 
ceptible in  the  extensors. 

9th. — The  splint  has  been  applied,  and  the  arm  has 
been  galvanized  daily.  The  contractility  of  the  exten- 
sors and  supinators  has  markedly  increased. 

23d. — The  fingers  have  become  sore  from  the  pres- 
sure of  the  instrument.  The  index  finger  is  but  little 
improved.  The  middle  finger  is  better,  and  the  little 
and  ring  fingers  are  very  much  so,  being  now  almost 
straight.  The  wrist  can  be  extended  perfectly,  so  that 
the  knuckles  can  be  brought  to  a  level  with  the  back 
of  the  forearm.  When  so  extended,  the  fingers  are  half 
bent.  But  when  the  WTist  is  dropped  they  can  be 
extended  by  the  patient.  In  doing  this  they  always 
involuntarily  spread  out  in  a  fan  shape,  owing  to  the 
action  of  the  dorsal  interossei. 

It  Vv^ould  appear  that  the  chief  resistance  to  proper 
extension  was  due  to  the  contraction  of  the  flexor  carpi 
radialis  and  the  flexor  tendon  of  the  index  finger,  both 
of  which  are  very  tense.  I  proposed  to  divide  these 
subcutaneously ;  but  the  child's  friends  would  not  give 
their  consent,  and  the  patient  was  consequently  dis- 
charged from  the  hospital. 

In  this  case,  also,  wq  had  the  partial  loss  of  supina- 
tion and  of  extension  dependent  on  paralysis  of  the 
posterior  interosseous  nerve ;  whilst  those  movements 
that  were  due  to  the  interossei  and  lumbricales  were 
perfect.  The  contraction  of  the  flexors,  which  had 
become  very  marked,  was  apparently  due  to  the  loss  of 
action  of  their  antagonist  muscles.  It  was  most  marked 
in  the  flexors  towards  the  radial  aspect  of  the  forearm, 
and  was  also  associated  with  a  tonic  pronation  of  the 
limb.     The  muscles  thus  injuriously  affecting  its  move- 


240  MEDICO-LEGAL   ASPECTS    OF 

ment  had  apparently  undergone  some  rigid  atrophy,  and 
I  regret  that  the  child's  friends  would  not  allow  tenot- 
omy, as  it  offered  a  good  prospect  of  cure.  The  fall  in 
the  temperature  of  the  hand  was  ver}^  marked.  It 
amounted  to  at  least  8.5°  F.,  and  how  much  more  it 
was  impossible  to  say,  owing  to  the  marking  of  the 
thermometer  not  admitting  of  a  lower  degree  being 
noted.  But  the  difference  between  the  two  hands  in 
this  respect  was  most  obvious  and  very  sensible  to  the 
touch.  This  great  fall  in  the  temperature  of  the  hand 
is  very  remarkable  when  we  reflect  that  it  was  due  to 
paralysis  of  a  branch  of  the  musculo-spiral  which  is 
not  directly  distributed  to  the  hand  ;  whilst  the  other 
nerves  of  the  hand — the  median  and  ulnar  and 
cutaneous  branch — were  intact,  and  gave  no  evidence  of 
paralysis.  The  movements  of  the  muscles  of  the  hand 
itself,  and  the  sensibility  of  the  skin  covering  it,  were 
normal. 


LECTURE  XII. 

ON  THE  MEDICO-LEGAL  ASPECTS  OF  CONCUSSION  OF 
THE  SPINE  AND  SHOCK  OF  THE  NERVOUS  SYSTEM 
AND    ON   THEIR    DIAGNOSIS. 

There  is  no  subject  in  forensic  medicine  more  impor- 
tant, and  there  are  few  more  difficult,  than  that  which 
relates  to  the  correct  estimate  of  the  nature,  the  extent, 
and  the  probable  consequences  of  an  injury  of  the  nerv- 
ous system  sustained  in  a  railway  collision.  The  im- 
portance of  an  attentive  study  of  these  cases  does  not 
consist  merely  in  the  great  frequency  of  their  occur- 
rence, though  in  this  respect  they  stand  in  an  unhappy 
pre-eminence — greatly  exceeding  in  number  all  other 
cases  put  together  in  which  medicine  and  law  are  mu- 
tually brought  to  bear  upon,  and  have  to  co-operate  in, 
the  elucidation  of  the  truth.  But  the  consideration  of 
these 'Cases  from  a  medico-legal  point  of  view  is  a  mat- 


CONCUSSION   AND    SHOCK.  24 1 

ter  of  the  greatest  importance  by  reason  of  the  difficul- 
ties with  which  they  are  surrounded  and  the  obscurity 
in  which  they  are  enveloped.  In  this  respect  their 
investigation  resembles  somewhat,  and  is  only  equaled 
by,  that  of  cases  of  alleged  insanity. 

In  those  cases  of  injury  of  the  nervous  system  that 
become  the  subject  of  medico-legal  inquiry  there  is, 
as  in  cases  of  alleged  insanity,  no  material  difficulty 
experienced  in  the  determination  of  the  various  ques- 
tions that  may  arise  in  the  more  severe  and  obvious 
forms  of  disease.  But  it  is  far  otherwise  in  the  slighter 
and  more  obscure  cases.  In  these,  not  only  may  the 
question  be  raised  as  to  the  actual  existence  of  the 
alleged  symptoms,  but  their  existence  having  been 
admitted,  the  surgeon  must  determine  the  value  to  be 
put  upon  them  as  evidences  of  real  organic  disease,  or 
of  mere  functional  disturbance.  And  in  reference  to 
the  ultimate  fate  of  the  patient  he  must  state  to  what 
extent  recovery  is  likely  to  take  place,  and  when  it  may 
be  expected.  In  addition  to  all  the  intrinsic  difficul- 
ties which  are  necessarily  connected  with  such  cases, 
there  is  underlying  and  greatly  disturbing  their  simple 
professional  aspect  the  great  question  of  the  amount  of 
pecuniary  compensation  that  should  be  granted  for  the 
consequences  of  the  alleged  injury.  Here  we  have  a 
disturbing  element  that,  happily,  never  intrudes  itself 
into  other  questions  of  surgery,  and  into  very  few  of 
forensic  medicine.  But  it  is  an  element  of  disturbance, 
to  the  effects  of  which  due  weight  must  be  given  by 
the  medical  attendant  in  so  far  as  it  affects  the  morale 
of  the  patient,  for  it  is  apt  to  influence  him  injuriously 
in  more  respects  than  one,  by  leading  him  either  wil- 
fully or  unconsciously  to  exaggerate  his  symptoms,  just 
as  he  is  very  apt  to  over-estimate  his  business  losses  and 
the  pecuniary  expenses  entailed  by  the  injury. 

But,  remember,  if  I  advise  you  not  to  neglect  to  take 
this  question  of  pecuniary  compensation  into  your  con- 
sideration, it  is  only  so  far  as  it  affects  the  patient's 
symptoms  and  the  estimate  he  forms  of  his  own  con- 
dition. In  no  other  way  can  you  as  medical  men — 
either  as  the  surgeon  to  the  railway  company,  or,  still 
16 


242  MEDICO-LEGAL  ASPECTS   OF 

less,  if  possible,  as  the  private  medical  attendant  of  the 
patient,  have  anything  whatever  to  do  with  the  matter. 
This  is  a  question  that  is  altogether  out  of  our  prov- 
ince. A  medical  man  who  considers  it  in  any  way  ex- 
cept on  the  mental,  and  through  that  on  the  physical, 
state  of  the  patient,  meddles  with  what  neither  concerns 
him  nor  his  profession,  and  places  himself  in  a  false  and 
unenviable  position.  Let  me,  therefore,  urge  upon  you, 
when  you  are  engaged  in  these  compensation  cases, 
never  under  any  circumstances  to  allow  yourselves  to 
be  drawn  into  a  discussion  as  to  the  amount  of  money 
payment  to  be  made  to  the  sufferer,  unless  the  matter 
is  expressly  referred  to  you  by  the  counsel  employed 
by  both  parties.  But  even  then  I  would  advise  you,  if 
possible,  to  avoid  being  placed  in  the  undesirable  posi- 
tion of  arbitrator.  You  may  be  sure  that  neither  party 
will  be  satisfied  with  your  decision.  The  fact  is,  that 
a  compensation  claim  for  alleged  injury  is  made  up  of 
various  elements,  of  which  the  personal  injury  is  only 
one.  This,  which  is  alone  the  surgeon's  province,  in 
reality  often  counts  for  very  little  in  the  case.  The 
losses  sustained  in  business ;  the  expenses,  medical  and 
others,  directly  incurred  by  the  patient  or  to  which  he 
is  liable  to  be  put  as  the  result  of  the  injury,  constitute, 
as  a  rule,  the  heavier  and  more  important  items  in  the 
claim  for  compensation ;  and  these  are  matters  that  lie 
in  the  province  of  counsel,  attorneys,  and  accountants, 
and  are  altogether  foreign  to  that  of  the  surgeon. 
Mental  sufferings,  bodily  pain,  and  disability,  the  dimi- 
nution of  that  physical  and  mental  vigor  in  which  the 
enjoyment  of  life  so  largely  consists,  even  complete 
annihilation  of  the  prospects  of  a  life,  weigh  lightly  in 
the  scales  of  Justice,  which  are  made  to  kick  the  beam 
only  by  the  weight  of  the  actual  money  loss  entailed 
by  the  accident. 

When  a  person  who  has  been  present  in  a  railway 
accident,  and  who  alleges  that  he  has  been  injured,  is 
presented  to  you  for  your  surgical  opinion,  you  will  find 
that  the  case  has  to  be  regarded  from  four  points  of 
view,  viz. : — 

I.  As  to  whether  he  has  really  been  injured. 


CONCUSSION   AND    SHOCK.  243 

2.  If  injured,  what  is  the  nature  and  extent  of  the 
injury? 

3.  Whether  the  injuries  are  permanent  or  not  ? 

4.  If  not  permanent,  then  when  will  he  be  restored  to 
health  ? 

Now  the  difficulty  of  determining  these  points,  and 
of  answering  these  questions,  more  especially  the  two 
first,  will  depend  greatly  upon  whether  you  are  the 
medical  attendant  of  the  patient  and  are  employed  on 
his  behalf,  or  are  engaged  for  the  interests  of  the  rail- 
way company. 

If  you  are  the  medical  attendant  of  the  sufferer  from 
the  alleged  negligence  of  the  company's  servants,  or  are 
consulted  by  him,  you  will  have  abundant  opportunities 
of  seeing  him  and  of  judging  of  him  at  different  times 
— often,  perhaps,  when  he  does  not  expect  your  visit. 
If  you  happen  to  be  his  regular  medical  attendant,  you 
will  be  able  to  compare  his  physical  and  mental  state 
after  the  accident  with  what  it  was  previous  to  that 
occurrence.  But  the  case  is  widely  different  if  you  are 
employed  on  behalf  of  the  railway  company,  whether 
as  their  regular  surgeon  or  for  the  purpose  of  advising 
them  with  respect  to  a  special  case.  In  these  circum- 
stances your  position  is  one  of  equal  difficulty  and  deli- 
cacy. In  accordance  with  the  lex  non  ^cripta — that 
somewhat  vague  code  of  honor  that  goes  by  the  name 
of  ''  professional  etiquette  " — you  cannot,  and  in  no 
case,  or  under  any  pretence  whatever,  ought  you  to  visit 
the  patient  after  you  have  given  him  the  first  attentions 
required  on  the  occurrence  of  the  accident,  and  after  he 
has  been  removed  to  his  own  house,  except  in  the  pres- 
ence of,  or  in  consultation  with,  his  own  medical  man. 
The  patient  is  not  yours — he  probably  does  not  wish  to 
consult  or  even  to  see  you.  Perhaps,  you  are  admitted 
to  an  interview  with  him  and  to  an  examination  of  him 
only  after  consultation  with  his  solicitors  and  by  their 
consent,  or  in  virtue  of  a  judge's  order.  He  most  prob- 
ably looks  upon  you  as  being  hostile  to  him,  and  as 
coming  with  the  view  of  making  light  of  his  misfortunes. 
Hence,  you  will  usually  have  but  few  opportunities 
allowed  you  of  seeing  the  patient — generally  only  one 


244  MEDICO-LEGAL  ASPECTS   OF 

■ — at  most,  two  or  three.  He  is  always  prepared  before- 
hand for  your  visit ;  he  is  excited,  annoyed,  or  appre- 
hensive with  respect  to  it ;  you  do  not  consequently 
see  him  in  his  usual  frame  of  mind  ;  and  the  mental 
disturbance  thus  occasioned  may  re-act  injuriously  upon 
and  greatly  aggravate  his  physical  ailments.  Above 
all,  you  have  no  opportunity  of  taking  him  unawares 
and  unprepared  when  your  visit  is  not  expected,  and 
when  you  would  have  a  good  opportunity  of  judging 
whether  this  symptom  or  the  other  in  reality  exists,  or 
if  it  exists  to  the  alleged  extent. 

The  difficulties  that  surround  an  investigation  by  the 
railway  surgeon  are  therefore  very  great  and  often 
embarrassing,  and  frequently  render  it  extremely  unsafe 
for  him  to  come  to  any  very  decided  opinion  upon  the 
case,  unless  the  symptoms  presented  by  it  are  very 
marked  and  of  the  nature  termed  "  objective." 

Much  delicacy  and  tact  also  are  required  in  these 
examinations  when  they  are  conducted  by  the  surgeons 
employed  by  the  railway  company.  The  patient  should 
be  dealt  with  kindly  and  in  a  straightforward  manner  ; 
his  tale  listened  to  w^ith  patience,  and  his  physical  exami- 
nation conducted  with  gentleness,  care  being  especially 
taken  to  avoid  the  infliction  of  unnecessary  pain,  or 
doing  anything  that  may  bear  the  interpretation  of 
cruelty  or  even  harshness. 

In  these  surgical  examinations  no  solicitor  should  be 
allowed  to  be  present  on  either  side  ;  and  should  the 
patient's  legal  adviser  insist  on  being  in  the  room,  it  is 
better  for  the  examining  surgeon  to  withdraw.  This 
investigation  is  a  purely  surgical  one.  The  presence  of 
the  patient's  own  medical  adviser  is  ample  protection 
to  his  interests,  and  a  solicitor  is  necessarily  out  of  place 
in  a  proceeding  which  is  beyond  the  limits  of  his  own 
profession.  I  have  actually  known  a  solicitor  attend 
with  a  short-hand  writer  to  take  down  notes  of  the  ques- 
tions and  replies — a  practice  which  I  have  heard  stig- 
matized by  the  Lord  Chief  Justice  of  England  as  most 
reprehensible. 

After  the  examination  has  been  made,  it  is  usual  and 
necessary  for  the  surgeon  to  send  in  his  "  Report  "  of 


CONCUSSION  AND   SHOCK.  245 

the  case  to  the  legal  advisers  of  the  plaintiff  or  the 
defendant.  This  Report  should  be  full  and  clear.  The 
symptoms  presented  by  the  patient  should  be  described, 
their  progress  traced,  your  opinion  given  as  to  the  actual 
condition  and  the  probable  future,  and  whenever  prac- 
ticable, the  grounds  on  which  you  found  that  opinion. 
If  the  examining  surgeons  agree  on  all  these  points, 
they  may  draw  up  a  Joint  Report.  Should  they  not  be 
of  the  same  opinion,  each  must  send  in  a  separate  one. 
These  Reports  are  usually  considered  confidential,  but 
erroneously  so  as  regards  that  of  the  railway  surgeon. 
It  has  recently  been  ruled  by  the  Lord  Chief  Justice 
(Farquhar  v.  Great  Northern  Railway  Company)^  that 
the  Report  thus  made  to  the  company  is  not  confiden- 
tial, but  that  the  plaintiff  may  have  access  to 
it.  His  Lordship  said  that  it  was  most  de- 
sirable that  a  medical  man  on  the  part  of  the  company 
should  have  an  opportunity  of  seeing  the  patient  in 
order  to  ascertain  the  nature  and  extent  of  the  injury. 
But  then,  on  the  other  hand,  the  patient  should  have 
the  corresponding  advantage  of  knowing  what  reports 
had  been  made  to  the  company  concerning  him.  The 
object  of  the  defendants  in  an  action  for  compensation 
for  alleged  injury  in  sending  their  medical  man  to 
examine  the  plaintiff  is  for  their  own  advantage,  not 
his.  It  is  to  determine  whether  he  really  has  been 
injured  as  alleged ;  if  so,  to  what  extent,  and  when  he 
is  likely  to  recover.  It  is  but  fair,  therefore,  to  the 
plaintiff  that  if  he  submits  to  the  intrusion  of  a  stranger 
and  suffers  himself  to  be  personally  and  minutely 
examined  by  one  whom  he  is  apt  to  regard  in  the  light 
of  a  hostile  witness,  he  should  be  made  acquainted  with 
the  opinion  that  has  been  formed  of  his  case.  The 
plaintiff's  course  will  be  very  much  guided  by  a  knowl- 
edge of  such  opinion.  If  the  patient  have  been  really 
and  seriously  injured,  it  is  only  just  and  right  that  he 
should  be  made  acquainted  with  the  candid  opinion  of 
the  medical  man  sent  to  examine  him.  If  he  over-esti- 
mate his  sufferings  and  find  that  the   defendant's  sur- 

*Vide  Solicitors^  Journal  Ann.  Reports,  Jan.  30,  1875,  p.  236. 


246  MEDICO-LEGAL  ASPECTS  OF 

geon  suspects  him,  he  will  be  more  likely  to  take  a  less 
serious  view  of  his  case  and  to  accept  reasonable  com- 
pensation. Whereas,  if  he  be  wilfully  misrepresenting 
his  condition  he  will  be  little  disposed  to  submit  him- 
self to  the  searching  cross-examination  of  counsel  if  he 
know  that  the  surgeon  employed  on  behalf  of  the  rail- 
way company  has  detected  his  fraud.  In  all  cases  the 
cause  of  truth  and  justice  would  be  materially  furthered 
in  these  cases  if  the  medical  men  on  either  side  were  to 
meet  and  confer  upon  the  case,  and  determine  if  possi- 
ble on  some  conjoint  report.  The  difference  of  opinion 
between  them  would  probably  be  found  to  be  narrowed 
down  to  one  or  two  points — probably  to  questions  con- 
nected with  the  duration  rather  than  within  the  nature 
of  the  alleged  injury;  and  those  unseemly  conflicts  of 
opinion  which  occasionally  occur  in  courts  of  law  would 
be  in  a  great  measure  avoided.  They,  not  uncom- 
monly, now  occur  from  a  medical  witness  suddenly 
"  springing "  upon  the  court,  a  new  theory  as  to  the 
nature  and  extent  of  the  injury,  or  making  a  positive 
statement  as  to  the  existence  of  other  symptoms  of 
which  the  surgeons  had  never  heard,  and  consequently 
had  no  opportunity  of  verifying  or  denying. 

Now  let  me  proceed  to  tell  you  generally  how  to 
determine  an  answer  to  the  two  first  questions  that  will 
present  themselves  to  you  in  all  these  cases,  viz.: 

1.  Whether  the  patient  has  really  been  injured  ;  and, 

2.  If  injured,  then  what  is  the  nature  and  extent  of 
the  injury? 

The  answers  to  these  questions  involve  the  diagnosis 
of  the  case ;  and  here  let  me  tell  you  how  and  by  what 
method  you  may  be  led  to  arrive  at  the  truth  in  this 
important  particular. 

In  effecting  a  diagnosis  you  may  look  upon  a  patient 
very  much  in  the  same  way  as  a  lawyer  looks  upon  a 
reticent  witness  in  the  box.  You  must  take  it  that  you 
have  before  you  a  person  who  is  not  disposed  to  tell  the 
truth.  It  is  your  business  to  elicit  the  truth  ;  and  just 
as  a  skilled  counsel  employs  a  certain  method  which 
experience  has  taught  the  members  of  his  profession 
tends   to  elicit  that  truth — experience  confirmed,  per- 


CONCUSSION   AND   SHOCK.  247 

haps,  by  his  own  sagacity  and  natural  instinct — so  the 
surgeon  employs  a  certain  method  to  elicit  the  truth 
which  the  patient  is  perhaps  unable  to  reveal  even 
though  he  be  willing  to  do  so,  and  which  the  disease 
cannot  tell  us.  In  making  a  diagnosis  you  will  find  that 
you  have  to  employ  both  your  senses  and  your  judg- 
ment. In  fact,  a  diagnosis  is  established  by  a  method 
of  observation  ;  observation  being  nothing  more  than 
the  application  of  the  senses,  tempered,  modified,  and 
improved  by  the  judgment.  The  mere  use  of  the 
senses  will  not  enable  you  to  effect  a  diagnosis.  You 
may  see  without  perceiving.  You  may  hear  and  not 
be  capable  of  understanding.  You  may  touch  and  yet 
be  unable  to  feel.  You  must  learn  how  to  effect  a 
diagnosis  by  the  combined  influence  of  study  and  prac- 
tice. Mere  study  will  not  give  it  to  you.  No  man, 
however  much  he  may  consult  books,  and  hov/ever 
learned  he  may.be  in  surgical  literature,  can  possibly, 
by  the  aid  of  book-learning  alone,  distinguish  elasticity 
from  fluctuation.  No  surgeon  understands  intuitively 
the  nature  of  a  complicated  injury  or  disease  the  first 
time  he  sees  it.  You  must  complement  study  by  prac- 
tice. You  must  study  in  order  that  you  may  know 
what  you  may  expect  to  find,  and  this  you  will  learn 
from  the  accumulated  experience  of  your  predecessors, 
which  is  to  be  found  in  books,  or  heard  in  lectures.  To 
find  it  you  will  need  the  cultivation  of  your  senses.  It 
is,  therefore,  by  that  combined  influence  of  study  and 
practice,  of  learning  and  judgment,  that  a  diagnosis 
is  ultimately  effected. 

In  effecting  a  diagnosis  in  these  as  in  all  other  surgi- 
cal cases,  you  will  find  that  the  patient  v/ill  present  two 
distinct  classes  of  phenomena,  and  it  is  very  important 
to  bear  in  mind  the  distinction  and  the  difference  that 
exist  both  in  kind  and  in  importance  of  those  two 
classes.  He  will,  in  the  first  place,  present  a  series  of 
phenomena  which  are  recognizable  by  the  surgeon 
himself,  however  unable  the  patient  may  be,  from  his 
injury  or  disease,  to  explain  them.  These  are  com- 
monly called  objective,  and  are  described,  or  ought  to 
be  described,  in  surgical  language  as  "  signs."     Let  me 


248  MEDICO-LEGAL  ASPECTS  OF 

give  you  an  illustration.  A  man  is  brought  into  the 
hospital  unconscious,  with  a  laceration  of  his  scalp, 
with  a  depression  of  his  cranium,  and  with  bleeding 
from  the  ear.  He  is  unable  to  tell  you  a  single  word  ; 
but  you  recognize  his  condition  at  once  by  the  local 
signs  just  mentioned,  coupled  with  the  more  general 
signs,  perhaps,  of  dilated  pupil,  heavy  stertorous  breath- 
ing, and  slow  pulse.  These  are  the  signs  that  he  pre- 
sents, and  'these  signs  are  unmistakable  by  the  surgeon. 
They  indicate  at  once,  without  a  word  from  the  patient, 
without  the  necessity  of  putting  a  question  to  anyone, 
what  his  actual  condition  is. 

But  there  is  another  series  of  phenomena  presented 
by  the  patient  which  are  of  less  importance  than  those 
that  I  have  just  mentioned,  and  that  series  of  phe- 
nomena goes  by  the  name  of  "  symptoms."  They  are 
subjective — that  is  to  say,  they  are  not  recognizable  by 
the  surgeon,  but  are  taken  upon  the  statement  made 
by  the  patient.  The  surgeon  can  form  no  judgment  of 
them  except  so  far  as  the  patient  tells  him.  A  man, 
for  instance,  comes  to  the  hospital  complaining  of  a 
violent  pain  in  his  head.  You  cannot  possibly  deter- 
mine whether  he  has  got  that  pain  or  not,  except  by 
his  own  statement.  He  tells  you  he  has,  and  you  must 
take  it  that  he  has  got  it,  especially  if  he  presents  other 
phenomena  that  are  corroborative  of  that  statement. 
Pain  is  a  symptom.  All  symptoms  are  taken  upon  the 
assertion  of  the  patient,  and  they  are  all  incapable  of 
proof  by  the  surgeon,  except  so  far  as  his  reliance  on 
the  patient's  statement  is  concerned,  whatever  be  the 
value  of  that  as  a  matter  of  proof.  You  will  therefore 
see  that  there  is  an  immense  difference  in  point  of 
value  as  well  as  in  kind  between  a  sign  and  a  symptom. 
But  there  is  a  further  difference  between  the  two.  A 
sign  indicates  not  only  the  fact  of  a  lesion,  but  it  indi- 
cates the  very  nature  of  that  lesion  in  the  majority  of 
cases.  It  is,  or  it  may  be,  the  lesion  itself.  A  symp- 
tom merely  indicates  the  fact  of  there  being  a  dis- 
turbance of  some  kind,  but  it  does  not  indicate  more 
than  that.  It  in  no  degree  shows  what  the  nature  of 
that    disturbance   is.      In    making   a   diagnosis,   then, 


CONCUSSION  AND   SHOCK.  249 

always  bear  in  mind  the  difference  of  value  between 
signs  and  symptoms,  between  the  objective  and  subjec- 
tive phenomena  presented  by  the  patient. 

The  symptoms  presented  by  the  patient  himself  are, 
as  I  have  already  said,  subjective — they  are  only  known 
to  and  must  be  described  by  the  patient  himself;  and 
here  the  surgeon  gets  upon  totally  different  ground, 
and  has  to  exercise  a  considerable  amount  of  caution  in 
effecting  his  diagnosis,  because  the  patient  will  very 
frequently  do  one  of  three  things.  He  may  uncon- 
sciously exaggerate  his  symptoms — that  is  a  condition 
that  is  extremely  common  in  nervous  and  hysterical 
persons ;  he  exaggerates  not  only  the  actual  existence 
of  any  symptom,  but  its  relative  importance  to  others. 
One  symptom  has  chiefly  attracted  his  attention,  and 
on  that  he  dwells.  He  employs  exaggerated  language 
in  describing  it ;  he  will  tell  you  that  he  has  got  an 
"agonizing"  pain,  a  "distracting"  pain;  he  will  use 
the  strongest  expletives  in  that  way  in  connection  with 
his  symptoms,  often  unconsciously  exaggerating  the 
importance  of  one  particular  symptom.  Then,  again, 
he  will  sometimes,  and  for  various  reasons,  consciously 
and  designedlv  either  exaggerate  or  conceal  symptoms. 
Patients  often  do  both — unconsciously  exaggerate  and 
wilfully  mislead — and  it  is  very  important  for  the  sur- 
geon not  to  be  deceived  in  these  respects,  and  to  use 
his  utmost  powers  of  cross-examination  and  of  search- 
ing enquiry  in  order  to  elicit  whether  symptoms  which 
are  described  really  exist,  or  whether  symptoms  which 
in  reality  do  exist  are  designedly  kept  in  the  back- 
ground. Here  the  difficulties  of  diagnosis  become 
great,  but  fortunately  it  is  but  rarely,  except  in  cases  of 
nervous  shock,  that  the  surgeon  has  to  deal  with  cases 
in  which  the  phenomena  presented  to  him  are  purely 
subjective,  and  in  which  subjective  cannot  be  supple- 
mented or  corrected  by  objective  phenomena  which  I 
have  already  described  as  being  so  infinitely  more 
important. 

Well,  then,  when  we  have  to  give  an  answer  to  the 
first  question,  viz.,  whether  the  patient  has  really  been 
injured,  or  whether  he   is  malingering,  let  me  always 


250  MEDICO-LEGAL  ASPECTS   OF 

advise  you  to  look  out  for  some  objective  symptom — 
some  sign  on  which  you  may  rely  as  being  beyond  the 
patient's  control,  incapable  even  of  exaggeration, 
whether  that  exaggeration  be  wilful  or  unconscious. 

In  the  class  of  cases  that  we  have  been  considering 
the  chief  signs  on  which  you  may  place  reliance  as  con- 
sisting of  objective  phenomena,  the  verification  of 
which  does  not  admit  of  doubt,  are,  i.  Ophthalmoscopic 
signs  furnished  by  the  examination  of  the  fundus  oculi ; 
2.  Paralytic  phenomena ;  3.  Alteration  in  size  of  a 
limb ;  4.  Diminution  of  sensibility,  as  determined  by 
the  aesthesiometer :  5.  Diminution  or  loss  of  electric 
irritability  and  sensibility ;  6.  Unnatural  and  persistent 
rigidity  of  muscles  of  the  spine  or  limbs ;  7.  Diminu- 
tion or  elevation  of  the  temperature,  and,  8.  Indica- 
tions afforded  by  the  state  of  the  pulse,  tongue,  diges- 
tive organs,  etc.  Indications  furnished  by  one  or  other 
of  these  signs  cannot  deceive,  and  not  only  do  they  not 
deceive  as  to  the  actual  existence  of  definite  lesion  of 
the  nervous  system,  but  they  go  further,  and  they 
afford  valuable  and  reliable  information  as  to  the  extent 
and  degree  of  that  lesion,  and  thus  serve  as  foundations 
for  the  answer  to  the  second  question  I  have  put,  viz., 
Admitting  the  existence  of  an  injury  to  the  nervous 
system,  what  is  its  nature  and  extent  ? 

But  even  in  regard  to  objective  phenomena  you  may 
be  deceived,  unless  great  care  be  taken.  And  here  I 
must  tell  you  that  an  extensive  experience  in  railway 
compensation  cases  w411  probably  impress  you  more 
with  the  ingenuity  than  with  the  honesty  of  mankind. 
A  history  of  deception  practised  on  railway  companies 
by  alleged  sufferers  from  accidents  upon  their  lines, 
would  form  a  dark  spot  on  the  morality  of  the  present 
generation.  Railway  companies,  it  is  true,  are  not 
particularly  tender-hearted  in  their  dealings  with  the 
victims  of  their  own  negligence  and  mismanagement, 
and  too  often  treat  those  who  have  really  seriously  suf- 
fered with  a  degree  of  suspicion  which  is  as  unjust  as  it 
is  vexatious.  And  their  officials,  too,  frequently  throw 
every  obstacle  that  the  law  can  furnish  in  order  to 
retard  or  even  to  frustrate  a  just  and  equitable  com- 


CONCUSSION  AND   SHOCK.  25  I 

pensation  for  the  injuries  that  have  in  reality  been  sus- 
tained. But,  in  justification  of  the  companies,  it  may 
fairly  be  contended  that  they  are  so  frequently  the 
subjects  of  a  degree  of  deception  that  actually  amounts 
to  a  conspiracy  to  defraud  them,  that  the  public  is  not 
free  from  blame  if  suspicions  are  unjustly  aroused  and 
manifested  in  regard  to  some  cases  that  are  in  all 
respects  genuine.  I  will  relate  two  or  three  instances 
to  you  to  show  how  important  it  is,  even  when  objec- 
tive signs  present  themselves,  not  to  be  too  hasty  in 
concluding  that  these  are  the  bona  fide  results  of  the 
injuries  sustained. 

Thus  I  have  known  cases  in  which  persons  who  hap- 
pened to  be  in  a  railway  collision,  but  who  were  unin- 
jured by  it,  have  attributed  to  this  accident  injuries 
previously  and  elsewhere  sustained,  and  have  actually 
brought  actions  for  compensation  for  the  old  and 
antecedent  injury.  I  will  give  you  one  case  out  of 
several  that  have  come  to  my  knowledge.  The  wife  of 
a  "  respectable  tradesman  "  brought  a  child  about  eight 
years  of  age  to  consult  me  relative  to  an  inflamed  knee- 
joint.  She  stated  that  she  and  her  child  had  a  short 
time  previously  been  in  a  collision  on  a  railway ;  that 
the  child  was  thrown  out  of  her  lap  and  struck  its  knee 
violently  against  the  edge  of  the  opposite  seat.  There 
was  an  abrasion  of  the  skin  covering  the  patella,  cor- 
responding to  the  seat  of  the  alleged  blow.  The 
inflammation  of  the  joint  went  on  from  bad  to  worse, 
until  at  the  end  of  about  three  months  I  was  obliged  to 
amputate  the  leg.  An  action  was  brought  against  the 
company  by  the  father  of  the  child,  as  its  next  friend, 
for  the  loss  of  its  limb  consequent  on  the  injury  to  the 
knee  alleged  to  be  sustained  in  the  collision.  The  com- 
pany would  certainly  have  been  cast  in  very  heavy 
damages,  if  their  inquiries  had  not  led  them  to  a  knowl- 
edge of,  and  enabled  them  to  establish  the  fact  that,  about 
a  week  before  the  collision,  the  child  had  fallen  at  play  and 
cut  its  knee  upon  a  stone  ;  that  the  joint  was  inflamed  and 
under  treatment  at  the  time  of  the  collision,  and  that 
in  the  railway  accident  itself  it  had  escaped  all  injury. 

In  another  case  a  gentleman   alleged   that  he  had 


252  MEDICO-LEGAL   ASPECTS   OF 

received  an  injury  of  the  back  in  a  railway  collision. 
After  a  time  he  began  to  suffer  from  albuminuria.  His 
condition  was  attended  by  many  anomalous  symptoms, 
and  occasionally  with  the  presence  of  a  small  quantity 
of  blood  in  the  urine.  It  continued  for  many  months, 
resisting  the  treatment  to  which  he  was  subjected  by 
his  own  medical  attendant,  by  myself,  and  by  several 
physicians  who  saw  him  in  consultation  from  time  to 
time.  The  case  came  to  trial.  The  plaintiff  received 
heavy  damages,  and  very  speedily  got  rid  of  his 
albuminuria.  From  circumstances  that  subsequently 
came  to  my  knowledge  I  was  satisfied  that  the  albumen 
had  been  skilfully  mixed  with  the  urine. 

In  another  case,  a  patient  who  had  been  present  in  a 
railway  collision  continued  for  nearly  twelve  months  in 
a  state  of  complete  prostration  ;  suffering,  according  to 
his  own  statement,  intensely  from  pain  in  his  spine,  and 
being  utterly  incapacitated  for  business.  He  could  not 
stand  without  crutches,  and  was  barely  able  to  walk  a 
few  yards  with  them,  dragging  one  leg  in  a  helpless 
manner  behind  him.  He  received  ample  solatium,  and 
in  less  than  a  month  had  not  only  lost  the  pain  in  his 
back,  but  thrown  away  his  crutches,  and  had  so  far 
recovered  his  business  aptitude  that  he  was  able  to 
travel  many  hundred  miles  by  railway  in  the  active 
prosecution  of  his  business. 

I  mention  these  cases,  and  I  might  greatly  multiply 
them,  to  show  you  that  even  when  objective  symptoms, 
often  of  the  most  marked  character,  are  present,  you 
must  not  at  once  conclude  that  there  is  neither  impos- 
ture nor  gross  exaggeration. 

Diagnosis. — There  is  a  form  of  deception  occasionally 
practised,  against  which  it  is  necessary  for  the  surgeon 
to  be  on  his  guard.  It  consists  in  concealing  the  exist- 
ence of  an  old-standing  chronic  disease,  and  assigning 
the  symptoms  and  low  state  of  health  resulting  from  it 
to  the  accident  itself.  Thus  a  person  knowing  that  he 
suffers  from  chronic  albuminuria,  may  keep  the  surgeon 
in  ignorance  of  the  fact,  and  attribute  the  wasting, 
vomiting,  cerebral  and  ocular  disturbances  consequent 
on  this  affection  to  the  shock  of  the  accident. 


CONCUSSION   AND    SHOCK.  253 

It  is  difficult  to  lay  down  any  rules  for  the  guidance 
of  the  surgeon  in  such  cases.  The  diagnosis  must  at 
best  be  left  to  his  practical  tact  and  professional  saga- 
city. But  it  may  be  stated  broadly  that  when  he  finds 
that  the  patient  presents  symptoms  of  constitutional 
derangements  which  are  out  of  all  proportion  severe  as 
compared  with  the  nervous  shock,  his  suspicions  should 
be  roused,  and  a  minute  investigation  instituted  into 
the  patient's  antecedent  health  and  the  actual  state  of 
his  organs. 

I  have  already  spoken  of  the  comparatively  small 
value  to  be  attached  to  mere  subjective  symptoms  in 
comparison  to  what  is  to  be  given  to  objective  signs. 
But  yet  in  a  certain,  and  by  no  means  small,  proportion 
of  cases  of  nervous  shock,  these  are  the  only  phenomena 
that  will  present  themselves  to  you.  These  subjective 
symptoms  may  be  wilfully  invented  in  order  to  mislead, 
or  may,  if  existing,  be  either  consciously  or  uncon- 
sciously exaggerated. 

Malingerers  may  often  be  detected  by  taking  off 
their  attention  in  conversation ;  by  desiring  them  to 
show  their  tongue,  &c.,  and  then  finding  that  some 
symptom  of  which  they  made  great  complaint,  such  as 
pain  in  the  spine  on  pressure,  or  a  spasmodic  movement 
of  a  leg  or  an  arm,  was  no  longer  felt,  or  suddenly  ceased. 
But  although,  undoubtedly,  in  many  cases,  deception 
may  thus  be  readily  enough  detected  and  exposed,  yet 
this  test  is  by  no  means  an  infallible  one.  In  the  first 
place  the  malingerer  may  be  on  his  guard,  and  thus 
frustrate  the  attempt  to  entrap  him.  But  even  if  the 
pain  is  not  complained  of,  or  if  the  spasmodic  jerk  of 
the  limb  ceases  when  the  attention  of  the  patient  is 
called  off,  it  does  not  follow  that  he  is  practising  a 
cheat.  I  have  seen  a  spasmodic  jerk  of  the  leg  in  one 
case,  and  a  constant  tremor  of  the  hand  in  another, 
suddenly  cease  when  the  patient  was  desired  to  put  out 
his  tongue,  in  cases  of  disease  not  resulting  from  injury, 
in  which  there  was  no  suspicion  of,  and  no  object  to  be 
gained  by,  malingering.  And  as  to  the  spinal  tender- 
ness, I  have  found  it  disappear  in  hysterical  girls  when 
attention  was   strongly  directed   elsewhere.     We   must 


254  MEDICO-LEGAL  ASPECTS   OF 

not,  therefore,  necessarily  consider  the  cessation  of 
these  symptoms  when  the  attention  is  taken  off  as  evi- 
dence of  malingering,  but  we  may,  I  think,  fairly  take 
it  as  evidence  that  the  particular  symptom,  whether  it 
be  pain  or  spasm,  does  not  arise  from  organic  disease, 
but  is  the  consequence  of  mere  functional  disturbance, 
and  so  far  the  test  is  a  very  important  one. 

When  invented,  or  wilfully  exaggerated  in  order  to 
mislead,  the  fraud  may  usually  be  detected  by  a  surgeon 
accustomed  to  these  investigations,  finding  that  the 
symptoms  do  not  bear  a  due  proportion  to  one  another; 
that  one  is  brought  into  greater  prominence  than  the 
rest,  and  that  the  patient  contrives  to  direct  attention 
to,  and  to  lay  emphatic  stress  on  it.  There  is,  in  fact, 
an  absence  of  that  harmony  of  symptoms,  if  I  may  use 
such  an  expression,  which  characterizes  all  true  and 
real  diseases. 

The  same  may  be  said  with  regard  to  that  menda- 
cious exaggeration  which  is  so  constantly  found  asso- 
ciated with  the  hysterical  or  emotional  temperament, 
or  with  distinct  hysterical  and  emotional  manifestations, 
both  in  the  male  and  in  the  female.  In  such  persons 
the  exaggeration  does  not  confine  itself  to  one  symptom, 
but  prevades  the  whole  of  the  condition,  mental  as  well 
as  physical. 

In  making  a  diagnosis  founded  on  purely  subjective 
symptoms,  you  must  then  most  certainly  take  the  entire 
condition  of  the  patient  and  estimate  its  value  as  a  whole. 
Judge  if  the  parts  of  which  it  is  composed  are  consis- 
tent with  the  alleged  conditions,  and  are  in  proper 
harmony  or  relation  with  one  another.  In  these 
cases  you  must  take  the  whole  group  of  symptoms. 
It  is  most  unfair  to  break  it  up  and  to  dissect  each 
separately.  Any  one  symptom  may  be  common  to 
several  conditions ;  may  by  itself  indicate  nothing 
positive  or  precise,  but  in  their  entirety  the  symptoms 
may  be  indicative  of  a  state  of  real  diseaser  Thus,  for 
instance,  a  pain  in  the  head,  impairment  of  memory, 
confusion  of  thought,  inability  to  maintain  a  continuous 
train  of  thought,  incapacity  for  ordinary  business  of 
life,  dreams  of  a  distressing  character,  weakness  of  sight, 


CONCUSSION  AND   SHOCK.  255 

general  debility,  an  irritable  temper,  muscular  weak- 
ness, coldness  of  extremities,  quick  and  feeble  pulse, 
&c.,  may  each  individually  be  referable  to  a  vast 
variety  of  constitutional  and  local  conditions,  but  if 
taken  collectively,  and  as  a  group,  they  certainly  indi- 
cate a  weakened  and  irritated  nervous  system,  and 
if  following  close  upon  an  injury  which  induces  general 
shock  of  the  nervous  system,  or  which  influences  the 
nervous  centres,  may  be  fairly  taken  as  the  result  of  such 
injury. 

In  reference  to  this  general  discussion  I  may  fairly 
put  the  matter  thus:  that  one  single  objective  sign, 
as,  for  instance,  the  loss  of  electric  irritability  in  the 
muscles  of  one  leg,  may  be  taken  by  itself  and  indepen- 
dently of  any  other  sign,  symptom,  or  abnormal  manifes- 
tation, as  being  absolute  and  irrefragable  evidence  of 
paralysis  of  that  limb,  consequent  upon  spinal  lesion. 
Whereas  no  one  of  the  subjective  symptoms  that  I  have 
just  mentioned  is  by  itself  proof  of  any  disease  what- 
ever. Any  one  of  them  may  be  the  simple  consequence 
of  fatigue,  of  exhaustion  from  excesses,  &c.,  but  yet 
taken  collectively,  they  may  fairly  be  taken  as  evidence 
of  nervous  shock.  And  the  weight  to  be  attached  to 
them  is,  I  need  not  say,  greatly  increased  by  the  deter 
mination  of  the  co-existence  of  one  or  more  of  the 
objective  signs  already  mentioned. 

It  is  important  to  make  the  diagnosis  between  the 
three  pathological  conditions  that  may  result  from 
concussion  of  the  spine,  viz.,  myelitis,  meningitis 
(separately  or  combined),  and  anaemia  of  the  cord.  And 
the  importance  of  the  diagnosis  rests  on  this  point,  that 
in  the  two  first  conditions  the  primary  inflammation  is 
apt  to  be  followed  by  such  changes  in  the  structure  of 
the  cord  and  its  membranes  as  will  leave  organic  lesions 
— possibly  of  a  permanent  character — ^whilst  in  anaemia 
of  the  cord  nutritive  changes  seldom  go  on  to  permanent 
impairment  of  function ;  and  the  disease  is,  as  a  rule, 
far  more  amenable  to  treatment. 

''  Weakness "  and  "  paralysis "  are  not  convertible 
terms  when  applied  to  the  condition  of  the  muscles  of 
a  limb.     In  "  weakness"  all  the  movements  of  which  a 


256  MEDICO-LEGAL  ASPECTS   OF 

part  is  naturally  capable  are  perfectly  and  equably  per- 
formed, though  their  force  is  lessened,  and  the  possible 
duration  of  their  action  materially  curtailed.  But  in 
"paralysis"  their  is  either  complete  loss  of  all  motility 
of  the  muscles  of  a  part,  or  there  is  an  irregularity  in 
the  movements  of  which  it  is  normally  susceptible ; 
some  being  wholly  lost,  whilst  others  are  more  or  less 
persistent.  There  is  a  loss  of  equipoise  between  opposite 
and  antagonistic  sets  of  muscles,  and  thus  various  devi- 
ations of  the  part  from  its  natural  shape  may  be 
occasioned,  such  as  dropping,  contraction,  inversion,  or 
extension. 

In  making  the  diagnosis  between  spinal  anaemia, 
myelitis,  and  meningitis,  there  are  four  conditions  to 
be  attended  to  ;  namely,  the  local  symptoms,  the  influ- 
ence of  therapeutic  agents,  the  temperature  of  the  body, 
and  the  ophthalmoscopic  appearances. 

So  far  as  the  local  symptoms  are  concerned,  it  will 
be  found  that  in  spinal  anaemia  there  is  always  pain  at 
one  or  more  points  along  the  vertebral  column.  This 
pain  is  associated  with  diffused  cutaneous  hyperaesthesia 
of  the  back.  The  pain  is  severely  complained  of  if  the 
patient  is  moved  by  the  surgeon,  but  it  will  be  observed 
that  he  may  move  himself  in  dressing  and  undressing 
without  exhibiting  any  evidence  of  suffering.  Although 
there  is  much  cutaneous  hyperaesthesia,  there  is  often 
a  good  deal  of  deep-seated  tenderness,  especially  on 
pressing  on  either  side  of  the  spinous  process  in  the 
inter-vertebral  spaces.  The  paralysis,  if  any,  is  incom- 
plete, there  is  no  affection  of  the  sphincters,  no  cramps 
or  chronic  spasms ;  there  is  often  a  general  emotional 
or  hysterical  condition  associated  with  the  spinal  symp- 
toms ;  the  general  appearance  of  the  patient  is  anaemic, 
the  pulse  quick,  feeble,  and  compressible.  These  symp- 
toms are  not  progressive,  will  rapidly  attain  their  cul- 
minating point,  and  there  remain  stationary  for  a  great 
length  of  time. 

In  myelitis  the  pain  in  the  spine  is  localised,  there  is 
little  if  any  cutaneous  hyperaesthesia.  The  localized 
pain  is  greatly  increased  by  all  movements  of  flexion, 
rotation,    or   by   pressure    downwards.      It    is   greatly 


CONCUSSION   AND    SHOCK.  257 

increased  by  percussion,  the  application  of  heat,  or  any 
act,  indeed,  which  influences  the  spinal  column  suffi-^ 
ciently  deeply  to  convey  an  impression  to  the  contained 
inflamed  medulla.  There  is  in  these  cases  always  a 
sensation  as  if  the  cord  were  tied  tightly  round  the 
body  on  a  line  corresponding  with  the  seat  of  inflam- 
mation. The  paralysis  is  often  quite  complete,  the 
sphincters  are  affected ;  there  is  atrophy  of  the  limbs, 
their  nutrition  being  acutely  interfered  with. 

In  meningitis  the  general  symptoms  more  or  less 
closely  resemble  those  of  myelitis,  for  indeed  it  is  almost 
impossible  to  find  meningitis  existing  without  a  certain 
inflammatory  implication  of  the  cord.  Theoretically, 
the  two  diseases  may  be  considered  apart,  but  clinically 
they  are  almost  invariably  associated.  In  meningitis, 
however,  there  are  these  additional  symptoms,  clonic 
spasms,  often  of  a  painful  character,  frequently  more 
or  less  permanent  contraction  of  certain  muscles  or 
groups  of  muscles,  and  in  both  myelitis  and  meningitis 
there  is  as  a  rule,  a  total  absence  of  the  hysterical  con- 
dition. 

There  are  two  therapeutic  tests  which  are  of  consid- 
erable value  in  confirming  the  diagnosis  between  these 
several  conditions.  Spinal  anaemia  is  always  benefitted 
by  strychnine  and  iron.  It  is  usually  considerably 
aggravated  by  the  bromides.  The  reverse  is  the  case 
in  meningo-myelitis.  In  this  condition  strychnine 
greatly  aggravates  the  symptoms  which  the  bromides 
commonly  have  a  tendency  to  alleviate,  those  at  all 
events  that  are  dependent  upon  the  concomitant  cere- 
bral irritation. 

The  ophthalmoscopic  appearances  are  also  of  con- 
siderable service  from  a  diagnostic  point  of  view.  In 
spinal  anaemia  we  have  a  pallid  condition  of  the  optic 
disc,  which  in  the  more  advanced  cases  may  proceed  to 
white  atrophy.  In  the  inflammatory  states  of  the  cord 
and  its  membranes,  more  especially  in  meningitis,  there 
is  considerable  hypersemia  of  the  fundus  of  the  eye. 

There  are  six  special  conditions  from  which  the 
diagnosis  of  spinal  concussion  has  to  be  made.  The)- 
are:    i.  The  secondary  consequences  of  cerebral  com- 

17 


258  MEDICO-LEGAL  ASPECTS   OF 

motion ;    2.  Rheumatism  ;    3.  Hysteria ;    4.  Injury  to 
nerve  trunks ;    5.  Typhoid  fever ;   6.  SyphiHs. 

1.  From  the  secondary  effects  of  cerebral  commotion 
it  is  not  difficult  to  diagnose  the  consequences  of  con- 
cussion of  the  spine  in  those  cases  in  which  the  mischief 
is  limited  to  the  vertebral  column.  The  tenderness  of 
the  spine,  the  pain  on  pressure  and  movement,  the 
rigidity  of  its  muscles,  and  the  absence  of  any  distinct 
sign  of  cerebral  lesion,  will  sufficiently  mark  the  precise 
situation  of  the  injury. 

But  it  must  be  remembered  that  the  two  conditions 
of  cerebral  and  spinal  concussion  often  co-exist  pri- 
marily. The  shock  that  jars  injuriously  one  portion  of 
the  nervous  system,  very  commonly  produces  a  cor- 
responding effect  on  the  whole  of  it,  on  brain  as  well  as 
on  cord ;  and,  as  has  been  fully  pointed  out  in  various 
parts  of  these  Lectures,  the  secondary  inflammations 
of  the  spine,  which  follow  the  concussion,  even  when 
that  is  primarily  limited  to  the  vertebral  column  and  its 
contents,  have  a  tendency  to  extend  along  the  con- 
tinuous fibrous  and  serous  membranes  to  the  interior 
of  the  cranium,  and  thus  to  give  rise  to  symptoms  of 
cerebral  irritation. 

2.  From  rheumatism  the  diagnosis  may  not  always 
be  easy,  especially  in  the  earlier  stages  of  the  disease, 
when  the  concussion  of  the  spine  and  the  consecutive 
meningitis  have  developed  pain  along  the  course  of  the 
nerves,  and  increased  cutaneous  sensibility  at  points. 
By  attention,  however,  to  the  history  of  the  case,  the 
slow  but  gradually  progressive  character  of  the  symp- 
toms of  spinal  concussion,  the  absence  of  all  fixed  pain, 
except  at  one  or  more  points  in  the  back,  the  secondary 
cerebral  complications,  the  gradual  occurrence  of  loss 
of  sensibility,  of  tinglings  and  formications,  the  slow 
supervention  of  impairment  or  loss  of  motor  power  in 
certain  sets  of  muscles — symptoms  that  do  not  occur  in 
rheumatism — the  diagnosis  will  be  rendered  compara- 
tively easy  ;  the  more  so  when  we  observe  that  in  spinal 
concussion  there  is  never  any  concomitant  articular 
inflammation,  and  that  although  the  urine  may  continue 
acid,  it  does  not  usually  become  loaded  with  lithates. 


CONCUSSION   AND    SHOCK.  259 

But  although  the  diagnosis  may  not  be  very  difficult 
from  the  more  acute  forms  of  rheumatism,  it  is  by  no 
means  easy  to  distinguish  some  of  the  secondary  conse- 
quences of  concussion  of  the  cord  from  the  more  chronic 
and  subacute  varieties  of  the  disease.  In  these  cases, 
however,  the  following  points,  if  attended  to,  may  clear 
up  the  nature  of  the  case.  In  rheumatism  of  this  form 
the  pain  is  muscular,  is  increased  by  movements  of  the 
affected  muscles,  and  is  influenced  by  atmospheric 
vicissitudes.  In  the  diffused  pains  of  spinal  concus- 
sion it  will  be  found  that  the  central  point  of  the  pain 
is  the  spine,  that  it  is  aggravated  by  pressure  over  or 
movements  of  the  vertebral  column,  that  muscles  may 
be  rigid  but  are  not  painful,  that  the  pain  takes  the 
anatomical  course  of  certain  sets  of  nerves,  of  those  in 
fact  connected  with  the  central  spinal  pain.  In  addi- 
tion to  this  the  history  of  the  case,  and  the  absence 
of  cerebral  complications  in  the  muscular  forms  of 
rheumatism,  will  determine  the  real  nature  of  the  case. 

In  some  cases  of  incipient  paraplegia  one  or  both 
knees  may  swell  and  become  tender  from  the  stress 
thrown  on  them  in  painful  efforts  to  walk,  and  possibly 
also  from  faulty  nutrition.  This  condition  may  lead 
to  a  suspicion  of  rheumatism ;  and,  indeed,  there  may 
be  gouty  or  rheumatic  arthritis  of  a  low  form  connected 
with,  and  partly  dependent  on,  the  paraplegic  state,  the 
symptoms  of  which  will  be  evident  in  the  limbs  below  the 
knees  and  quite  independently  of  any  affection  in  them. 

So  far  as  the  special  diagnosis  is  concerned  of  con- 
cussion of  the  cord  in  its  primary  and  secondary  symp- 
toms from  various  other  analagous  and  complicating 
conditions,  I  must  refer  to  other  parts  of  these  Lec- 
tures. Thus  you  will  find  the  diagnosis  between  hys- 
teria and  the  symptoms  of  Concussion  of  the  Cord 
given  in  Lecture  VIII.,  and  that  of  sacrodynia,  one 
of  the  most  frequent  and  embarrassing  complications 
or  independent  phenomena,  described  at  length  in 
Lecture  IX. 

3.  Hysteria. — From  this  manifestation  of  nervous 
disturbance  I  have  already  pointed  out  how  the  diag- 
nosis of  spinal  concussions  can  be  made  (Lect.  VIII.); 


26o  MEDICO-LEGAL  ASPECTS   OF 

I    need    not,  therefore,  repeat    the    cautions    I    there 
laid  down. 

4.  The  injury  sustained  by  a  large  nerve  trunk,  after 
its  escape  from  the  vertebral  canal,  may  lead  to  more 
or  less  paralysis  of  motion  and  sensation  of  the  extrem- 
ity or  of  the  parts  supplied  by  it.  In  this  case  the 
limitations  of  the  loss  of  nervous  power  to  the  limb  or 
even  to  one  part  of  a  limb — the  absence  of  all  central 
symptoms  either  in  the  spine  or  the  he.ad — will  deter- 
mine with  sufficient  accuracy  the  localized  nature  of 
the  injury. 

5.  It  might  at  first  scarcely  appear  possible  that  any 
chance  could  occur  of  mistaking  some  of  the  secondary 
effects  of  concussion  of  the  spine  for  the  initiatory 
symptoms  of  typhoid  fever.  But  yet  the  difficulty  may 
arise,  and  has  actually  occurred  in  two  cases  in  my  own 
experience.  There  is,  of  course,  no  difficulty  in  the 
more  advanced  stages  of  typhoid  by  attention  to  ther- 
mometric  indications,  diarrhoea,  the  characteristic  erup- 
tion, the  state  of  the  tongue,  pulse,  etc.  But  in  the 
early  stages  the  sudden  accession  of  cerebral  symptoms, 
such  as  frontal  headache,  delirium,  somnolence,  or  mani- 
acal excitement,  may  mislead  the  surgeon.  And  he 
may  incorrectly  refer  these  to  an  aggravation  of  the 
nervous  symptoms  resulting  from  the  accident,  when 
in  reality  they  are  due  to  this  invasion  of  the  initiatory 
stage  of  typhoid,  which  is  apt  to  develop  itself  with 
cerebral  complications,  owing  to  the  pre-existing  irrita- 
tion of  the  nervous  system.  In  one  case  which  Dr. 
Maudsley  saw  with  me,  the  patient,  some  weeks  after  a 
railway  collision,  in  which  he  had  been  severely  shaken, 
became  suddenly  maniacal,  stripped  himself  naked,  and 
rushed  out  of  the  house  in  the  middle  of  the  night  in 
this  condition.  The  cause  of  this  sudden  exacerbation 
of  nervous  symptoms  was  very  obscure  for  some  days, 
when  it  was  cleared  up  by  the  gradual  development  of 
typhoid  fever.  In  such  cases  as  these,  indeed,  the 
remark  that  I  have  already  made  more  than  once  is 
peculiarly  applicable,  viz.,  to  wait  for  time  to  clear  up 
the  diagnosis.  What  is  obscure  to-day  will  be  patent 
to  the  most  ordinary  observer  to-morrow. 


CONCUSSION  AND   SHOCK.  261 

6.  Syphilis. — In  syphiloma  of  the  cord  and  Its  mem- 
branes, various  symptoms  may  be  developed  that  closely 
resemble  those  presented  by  spinal  concussion  ;  but  here 
attention  to  the  history  of  the  case,  and  the  co-existence 
of  syphilitic  lesions  on  the  skin  or  mucous  membrane, 
will  determine  its  true  nature.  It  must  not,  however, 
be  forgotten  that  a  patient  suffering  from  constitutional 
syphilis  may  sustain  an  injury  of  the  spine,  adding  to 
the  ulterior  phenomena  of  spinal  meningitis  those  of  a 
specific  character. 


LECTURE  XIII. 

ON   PROGNOSIS   IN   CONCUSSION  OF  THE    SPINE   IN   ITS 
CLINICAL  AND    MEDICO-LEGAL  ASPECTS. 

The  prognosis  or  the  determination  of  the  course  that 
the  effects  of  an  injury  will  take,  and  of  the  probable 
state  of  health  of  the  patient,  is  one  that  is  surrounded 
by  difficulties  of  all  kinds,  and  one  on  which  it  is  often 
impossible  for  the  surgeon  to  venture  to  give  a  definite 
opinion.  Yet  it  is  on  this  point  that  he  is  commonly 
most  pressed  to  express  himself  dogmatically.  The 
greater  his  experience  the  less  ready  will  he  be  to  haz- 
ard a  positive  opinion.  For  he  will  be  able  to  call  to 
mind  many  cases  in  which  opinions  confidently  enter- 
tained and  expressed  by  surgeons  of  the  greatest  emi- 
nence, and  possibly  by  himself,  have  been  falsified  by 
the  subsequent  results.  Hence  he  will  seldom  venture 
on  anything  more  confident  than  a  belief  in  the  proba- 
bility of  a  given  result. 

The  prognosis  of  a  case  of  spinal  concussion  involves 
three  considerations ; 

1.  As  regards  the  life  of  a  patient.  Will  the  case 
terminate  fatally  or  not  ? 

2.  If  not  fatal,  whether  the  injuries  are  permanent 
or  not  ? 


262  PROGNOSIS   OF 

3.  If  not  permanent,  then  when  will  the  patient  be 
restored  to  health  ? 

The  prognosis  of  a  serious  injury  of  any  part  of  the 
nervous  system  is  always  bad.  I  mean  by  serious, 
either  severe  in  its  primary  effects  or  in  its  secondary 
consequences.  A  serious  injury  of  the  brain  is  never 
completely  recovered  from.  However  long  the  person 
may  live,  and  however  well  he  may  have  got  over  his 
accident,  traces,  in  some  shape  or  another,  will  continue. 
Change  of  character,  irritability  of  temper,  lessened 
aptitude  for  work  of  any  kind,  impairment  of  some 
senses,  as  of  vision ;  abolition  of  others,  as  of  taste  or 
smell.  All  this  is  familiar  to  us  after  such  injuries  of 
the  brain  as  produce  structural  changes.  I  believe  it 
to  be  in  some  respects  due  to  the  cord,  and  that  a 
structural  change  once  effected  as  the  result  of  injury 
is  permanent,  and  leaves  more  or  less  indelible  traces 
of  its  presence  in  the  modifications  it  induces  in  the 
functions  of  the  cord.  It  is  only  in  this  way  that  we 
can  explain  the  extreme  tenacity  in  the  persistence  of 
certain  symptoms  after  recovery  from  the  general  .effects 
of  the  injury  has  long  since  taken  place. 

I.  So  far  as  life  is  concerned,  it  is  only  in  those  cases 
of  severe  and  direct  blows  upon  the  spine,  in  which 
intra-spinal  haemorrhage  to  a  considerable  extent  has 
occurred,  or  in  which  the  cord  or  its  membranes  have 
been  ruptured,  or  in  other  ways  so  seriously  injured  that 
acute  softening  ensues,  that  a  speedily  fatal  termination 
may  be  feared.  In  such  cases  as  these  the  danger  is 
necessarily,  cceteris  paribus,  greater  in  the  cervical  than 
in  the  dorsal — in  the  dorsal  than  in  the  lumbar 
region. 

In  some  of  the  cases  of  concussion  of  the  spine,  fol- 
lowed by  chronic  inflammation  of  the  membranes  and 
of  the  cord  itself,  death  may  eventually  supervene  after 
several,  perhaps  three  or  four,  years  of  an  increasingly 
progressive  breaking  down  of  the  general  health,  and 
the  slow  extension  of  the  paralytic  symptoms  in  extent 
as  well  as  in  degree.  I  have  known  several  instances 
in  which  concussion  of  the  spine  has  thus  proved  fatal 
some  years  after  the  occurrence  of  the  accident.     And 


CONCUSSION   OF  THE  SPINE.  263 

Mr.  Gore,  of  Bath,  who  has  had  considerable  experience 
in  these  injuries,  writes  to  me  in  reference  to  the  case 
related  already,  that  this  is  the  third  fatal  case  of  which 
he  has  had  more  or  less  personal  knowledge,  the  time 
from  the  injury  to  the  occurrence  of  death  var>ang  from 
two  and  a  half  to  five  years. 

In  these  cases,  the  fatal  result  is  the  direct  effect  of 
the  structural  changes  that  take  place  in  the  cord  and 
its  membranes.  They  prove  in  the  clearest  and  most 
incontestable  manner  the  possibility  of  death  occurrmg 
after  a  lapse  of  several  years,  from  the  progressive 
increase  of  those  symptoms,  which  are  dependent  upon 
disease  of  the  nervous  system  from  concussion  of  the 
spine  occurring  from  slight  and  indirect  accidents,  and 
attended  by  the  usual  symptoms  of  such  injuries  ;  the 
fatal  termination  being  gradually  induced  by  the  slow 
and  progressive  structural  changes  which  take  place  m 
the  cord.  The  case  referred  to  establishes  the  fact 
beyond  doubt  that  such  a  fatal  termination  is  by  no 
means  impossible  after  an  interval  of  several  years,  m 
cases  of  concussion  of  the  spine  in  which  deep-seated 
structural  changes  have  developed  in  the  cord. 

The  probability  of  such  a  melancholy  occurrence  is 
greatly  increased  if,  after  a  year  or  two  have  elapsed 
from  the  time  of  the  occurrence  of  the  accident,  the 
symptoms  of  chronic  meningo-myelitis  either  continue 
to  be  gradually  progressive,  or,  after  an  interval  of  qui- 
escence, suddenly  assume  increased  activity. 

In  fact,  it  is  the  excitation  of  this  very  form  of  dis- 
ease, viz.,  chronic  inflammation  of  the  spinal  cord  and 
its  membranes,  that  constitutes  the  great  danger  in 
these  injuries  of  the  spine.  When  it  has  once  gone  on 
to  the  development  of  atrophy,  softening,  or  other 
structural  changes  of  the  substance  of  the  cord  itself, 
complete  recovery  is  impossible,  and,  ultimately,  death 
is  not  improbable. 

Ollivier  states  as  the  result  of  his  experience,  that 
although  persons  affected  with  chronic  myelitis  may 
live  for  fifteen  or  twenty  years,  yet  that  they  more  com- 
monly perish  within  four  years.  This  opinion  as  to  the 
probable  future  of  patients  unfortunately  affected  by 


264  PROGNOSIS   OF 

this  distressing  disease  js  perhaps  too  gloomy,  so  far  as 
the  fatal  result  is  concerned,  but  it  is  an  evidence  of 
the  very  serious  view  that  a  man  of  such  large  experi- 
ence in  the  diseases  of  the  cord  took  of  the  probable 
issue  of  a  case  of  chronic  inflammation  of  that  structure, 
and  it  is  doubtless  explicable  by  the  fact  that  OUivier's 
experience  has  necessarily  been  chiefly  drawn  from  idio- 
pathic or  constitutional  affections  of  that  portion  of  the 
nervous  system  ;  and  these  may  justly  be  considered  to 
be  more  frequently  fatal  than  those  forms  of  the  disease 
that  arise  from  accident  to  an  otherwise  healthy  man 
not  predisposed  to  such  affections. 

Ollivier  takes  an  equally  unfavorable  view  of  the 
ultimate  result  of  spinal  meningitis,  and  probably  for 
the  same  reason.  He  says,"^  "  Is  spinal  meningitis  sus- 
ceptible of  cure  ?  All  observers  agree  in  stating  that 
death  is  the  inevitable  result."  In  this,  however,  there 
can  be  no  doubt  that  Ollivier  was  in  error.  I  have  seen 
cases  of  undoubted  spinal  meningitis  recover.  I  may 
instance  particularly  one  of  a  young  lady  14  years  of 
age,  with  an  enormous  congenital  spina  bifida  contain- 
ing more  than  one  hundred  ounces  of  fluid.  I  cured 
the  disease  by  repeated  tappings  and  pressure  combined. 
During  the  treatment  symptoms  of  spinal  meningitis 
came  on  with  opisthotonos  and  convulsive  movements, 
but  complete  recovery  gradually  took  place.  Ollivier 
qualifies  his  statement,  however,  by  saying  that  he  has 
found  in  one  case  after  death  from  other  disease,  old 
thickening  of  the  membranes  of  the  cord,  and  that 
Frank  relates  another  in  which  a  fatal  termination  did 
not  occur.  The  occurrence  of  convulsive  movements, 
however,  is  a  most  unfavorable  sign.  They  indicate 
the  existence  of  chronic  myelitis,  and  are  usually  asso- 
ciated with  deep  disorganization  of  the  structure  of  the 
cord.  They  are  of  a  most  painful  character,  and  are 
apt  to  be  excited  by  movements  and  shocks  of  the  body 
even  of  a  very  slight  character.  With  the  exception  of 
the  case  just  mentioned,  I  have  never  known  a  patient 
recover   who  has   been  afflicted   by  them,    progressive 

*  Vol.  ii.  p.  294. 


CONCUSSION   OF  THE   SPINE.  265 

paralysis  developing  itself,  and  the  case  ultimately 
proving  fatal.  Mr.  Gore,  of  Bath,  informs  me  that  he 
is  acquainted  with  two  cases  which  proved  fatal  at  long 
periods  of  time  after  the  accident,  in  both  of  which  this 
symptom  was  present.  One  of  these,  a  very  healthy 
lad  of  nineteen,  was  injured  on  October  29,  1863,  and 
died  May  11,  1866.  He  suffered  from  convulsive 
attacks,  with  extreme  pain  in  the  spine,  till  the  latter 
end  of  1864,  then  the  convulsions  ceased,  but  the  aching, 
wringing  spinal  pain  continued  ;  and  his  health  broke 
down  completely.  Phthisis,  to  which  there  was  no 
hereditary  tendency,  developed  in  the  following  spring, 
and  he  eventually  died  of  that  disease  two  years  and  a 
half  after  the  injury. 

From  all  this  it  is  certain  that  consussion  of  the  spine 
may  prove  fatal; — first,  at  an  early  period  by  the  severity 
of  the  direct  injury  (Case  13);  secondly,  at  a  more 
remote  date  by  the  occurrence  of  inflammation  of  the 
cord  and  its  membranes  ;  and,  thirdly,  after  the  lapse 
of  several  years  by  the  slow  and  progressive  develop- 
ment of  structural  changes  in  the  cord  and  its  mem- 
branes (Case  12). 

2.  But  though  death  may  not  occur,  is  recovery  cer- 
tain? May  the  effects  of  the  injury  not  be  permanent 
though  they  be  not  fatal?  Is  there  no  mid-state 
between  a  fatal  result,  proximate  or  remote,  and  the 
absolute  and  complete  recovery  of  the  patient  ? 

Now,  this  question  of  permanency  of  symptoms  or 
of  unlimited  duration  of  effects  of  injury  is  one  that 
you  must  approach  with  great  caution,  and  on  which  a 
definite  opinion  is  often  impossible.  Before  proceeding 
to  discuss  it,  let  us  inquire  what  is  meant  by  the 
"recovery  of  the  patient?"  When  you  are_  asked, 
''  In  your  opinion  will  this  patient  ever  recover  ?  "  what 
are  you  to  understand  by  that  question  ?  Is  it  meant 
whether  there  will  be  a  mitigation  of  the  symptoms — 
an  amelioration  of  health  to  some,  perhaps  even  a  con- 
siderable, extent ;  an  indefinite  prolongation  of  life,  so 
that  with  care,  by  the  avoidance  of  mental  exertion  and 
bodily  fatigue  of  all  kinds,  the  patient  may  drag  on  a 
semi-valetudinarian    existence    for    fifteen    or    twenty 


266  PROGNOSIS   OF 

years  ?  Is  this  the  meaning  of  the  question  ?  Is  it 
meant  that  after  a  time  even  he  may  be  able  to  return 
to  his  business — that  he  may  be  able  to  sit  in  his  office 
or  travel  about  the  country?  No,  certainly  not.  A 
man  may  do  all  this  and  yet  be  far  from  well — be  very 
far  from  having  recovered.  If  that  question  has  any 
definite  meaning,  it  is  whether  the  patient  will  in  time 
completely  and  entirely  lose  all  the  effects  of  the  injury 
he  has  sustained  ;  whether,  in  all  respets,  mentally  and 
bodily,  he  will  be  restored  to  that  state  of  intellectual 
vigor  and  of  corporeal  activity  that  he  enjoyed  before  the 
occurrence  of  the  accident ;  whether,  in  fact,  he  will 
ever  again  possess  the  same  force  and  clearness  of 
intellect,  the  same  aptitude  for  business,  the  same  per- 
fection of  his  senses,  the  same  physical  energy  and 
endurance,  the  same  nerve,  that  he  .did  up  to  the 
moment  of  his  receiving  the  concussion  of  his  spine. 

In  considering  the  question  of  recovery  after  con- 
cussion of  the  spine,  we  have  to  look  to  three  points : 
first,  the  recovery  from  the  primary  and  direct  effects 
of  the  injury  ;  secondly,  from  the  secondary  and  remote 
consequences  of  it ;  and  thirdly,  the  time  when  such 
recovery  is  likely  to  take  place. 

There  can  be  no  d.oubt  that  recovery,  entire  and  com- 
plete, may  occur  in  a  case  of  concussion  of  the  spine 
when  the  symptoms  have  not  gone  beyond  the  primary 
stage,  whei?  no  inflammatory  action  of  the  cord  or  its 
membranes  has  been  developed,  and  more  particularly 
when  the  patient  is  young  and  healthy  in  constitution. 
This  last  condition  indeed  is  a  most  important  one.  A 
young  man  of  healthy  organization  is  not  only  less 
likely  to  suffer  from  a  severe  shock  to  the  system  from 
a  fall  or  railway  injury  than  one  more  advanced  in  life, 
but,  if  he  does  suffer,  his  chance  of  ultimate  recovery 
will  be  greater,  provided  always  that  no  secondary 
symptoms  dependent  on  organic  or  structural  lesions 
have  developed  themselves. 

I  believe  that  such  complete  recovery  is  more  likely 
to  ensue  if  the  primary  symptoms  have  been  severe,  the 
result  of  direct  injury,  and  have  at  or  almost  immedi- 
ately after  the  occurrence  of  the  accident  attained  to 


CONCUSSION   OF  THE   SPINE.  267 

their  full  intensity.  I  have  seen  many  instances  of 
this,  and  would  refer  to  Cases  1,6,  7  as  being  illustra- 
tive of  this  fact. 

In  these  cases,  under  proper  treatment,  the  severity 
of  the  symptoms  gradually  subsides,  and,  week  by  week, 
the  patient  feels  himself  stronger  and  better,  until, 
usually  in  from  six  to  twelve  months  at  the  utmost,  all 
traces  of  injury  have  disappeared. 

But  incomplete  or  partial  recovery  is  not  unfrequent 
in  these  cases  of  severe  and  direct  injury  of  the  spine. 
Of  this,  Case  2  is  an  excellent  illustration.  The  patient 
slowly  recovers  up  to  a  certain  point  and  then  remains 
stationary,  with  some  impairment  of  innervation  in  the 
shape  of  partial  paralysis  of  sensation,  or  of  motion,  or 
both,  usually  in  the  lower  limbs.  The  intellectual  fac- 
ulties or  the  organs  of  sense  are  more  or  less  dis- 
turbed, weakened,  or  irritated,  the  constitution  is  shat- 
tered, and  the  patient  presents  a  prematurely  worn  and 
aged  look. 

In  such  cases  structural  lesion  of  some  kind,  in  the 
membranes,  if  not  in  the  cord,  has  taken  place,  which 
necessarily  must  prevent  complete  recovery.  When, 
therefore,  we  find  a  patient  who,  after  the  receipt  of 
severe  injury  of  the  spine  by  which,  the  cord  has  been 
concussed,  presents  the  primary  and  immediate  symp- 
toms of  that  condition,  such  as  have  been  described  in 
Case  I,  we  may  entertain  a  favorable  opinion  of  his 
future  condition,  provided  we  find  that  there  is  pro- 
gressive amelioration  of  his  symptoms,  and  no  evidence 
of  the  development  of  any  inflammation,  acute  or 
chronic,  of  the  membranes  and  the  cord. 

But  our  opinion  as  to  his  ultimate  recovery  must 
necessarily  be  very  unfavorable,  and  the  probability  of 
his  having  been  permanently  injured  will  be  greatly 
increased,  if  we  find  the  progress  of  amendment  cease 
after  some  weeks  or  months,  leaving  a  state  of  impaired 
innervation,  or  of  more  or  less  complete  paralysis.  And 
this  unfavorable  opinion  will  be  much  strengthened  if 
we  find  that  subsequently  to  the  primary  and  imme- 
diate effect  of  the  injury,  symptoms  indicative  of  the 
development  of  meningo-myelitis  have  declared  them- 


268  PROGNOSIS  OF 

selves.  Under  such  circumstances  of  the  double  com- 
bination, of  the  cessation  of  improvement  and  the 
supervention  of  symptoms  of  intra-vertebral  inflamma- 
tory action,  partial  restoration  to  health  may  eventu- 
ally be  expected ;  but  complete  recovery  is  hardly 
possible. 

When  a  person  has  received  a  concussion  of  the  spine 
from  a  jar  or  shake  of  the  body,  without  any  direct 
blow  on  the  back,  or  perhaps  on  any  other  part  of  the 
body,  and  the  symptoms  have  gradually  and  progres- 
sively developed  themselves,  the  prognosis  will  always 
be  very  unfavorable.  And  for  this  reason  :  that  as  the 
injury  is  not  suf^cient  of  itself  to  produce  a  direct  and 
immediate  lesion  of  the  cord,  any  symptoms  that 
develop  themselves  must  be  the  result  of  structural 
changes  taking  place  in  it  as  the  consequence  of  degen- 
eration ;  and  these  secondary  structural  changes  being 
incurable,  must,  to  a  greater  or  less  degree,  but  perma- 
nently, injuriously  influence  its  action. 

The  occurrence  of  a  lengthened  interval,  a  period  of 
several  weeks,  for  instance,  between  the  infliction  of  the 
injury  and  the  development  of  the  spinal  symptoms, 
is  peculiarly  unfavorable,  as  it  indicates  that  a  slow  and 
progressive  structural  change  has  taken  place  in  the 
cord  and  its  membranes,  dependent  upon  pathological 
changes  of  a  deep-seated  and  permanently  incurable 
character.  The  progressive  decadence  of  health  and 
signs  of  disintegration  of  the  nervous  system  are  very 
slow  in  these  cases.  At  first  the  patient  merely  feels 
weak,  is  not  quite  as  well  able  to  do  a  long  day's  busi- 
ness or  professional  work  as  before ;  his  friends  and 
family  observe  a  change  in  his  character ;  he  becomes 
irritable,  or  taciturn  and  sullen ;  he  looks  aged  and 
careworn  ;  his  incapacity  for  business  increases ;  his 
handwriting  is  changed  for  the  worse  ;  the  powers  of 
walking  are  lessened,  and  the  disposition  to  take  exer- 
cise diminishes.  All  this  goes  on  for  many  months,  for 
a  year  or  more  ;  then  one  leg  begins  to  fail,  usually  the 
left ;  he  complains  of  coldness  of  the  extremities,  of 
various  uneasy  sensations  in  the  hands — tinglings,  &c. ; 
his  vision  becomes  impaired  ;   he   becomes   very  emo- 


CONCUSSION   OF   THE   SPINE.  269 

tional,  almost  hysterical,  between  the  fits  of  irritability, 
and  at  last  unmistakable  symptoms  of  paraplegia  or  of 
structural  brain  disease,  hemiplegia,  possibly  aphasia, 
develop  themselves.  But  the  progress  of  the  symp- 
toms, however  slow,  has  been  continuous  from  the 
time  of  the  accident.  There  may  have  been  fluctua- 
tions in  their  severity,  but  never  a  complete  interval 
of  the  same  good  health  that  existed  before  this 
occurrence. 

Abercrombie  truly  says,  '^  Every  injury  of  the  spine 
should  be  considered  as  deserving  of  minute  attention, 
and  the  most  active  means  should  be  employed  for  pre- 
venting or  removing  the  diseased  actions  which  may 
result  from  it.  The  more  immediate  object  of  anxiety 
in  such  cases  is  inflammatory  action  ;  and  we  have 
seen  that  it  may  advance  in  a  very  insidious  manner, 
even  after  injuries  which  were  of  so  slight  a  kind  that 
they  attracted  at  the  time  little  or  no  attention." 

Well,  then,  when  you  see  a  patient  suffering  from 
the  secondaiy  effects  of  a  slight  injury  of  the  spine, 
these  effects  having  developed  in  an  insidious  but  pro- 
gressive manner,  examine  him  with  minute  attention  ; 
and  if  you  find  evidence  of  inflammatory  action  in  the 
cord  and  its  membranes,  as  indicated  by  symptoms  of 
cerebral  irritation,  spinal  tenderness  and  rigidity,  modi- 
fications of  sensation,  as  pains,  tinglings,  and  numbness 
in  the  limbs,  and  some  lo&s  of  muscular  or  motor  power, 
with  a  quick  pulse,  functional  derangement  of  the 
abdominal  and  pelvic  organs,  and  a  shattered  consti- 
tution, you  must,  at  any  period  of  the  case,  however 
early,  give  a  most  cautious  prognosis.  And  if  many 
months — from  six  to  twelve — had  elapsed  without  any 
progressive  amelioration  in  the  symptoms,  you  may  be 
sure  that  the  patient  will  never  recover  so  as — to  use 
the  common  phrase — "  to  be  the  same  man  "  that  he 
was  before  the  accident.  But  if,  instead  of  remaining 
stationary,  a  progressive  increase  in  the  symptoms, 
however  slow  that  may  be,  is  taking  place,  more  and 
more  complete  paralysis  will  ensue,  and  the  patient 
will  probably  eventually  die  of  those  structural  spinal 
lesions  that  have  been  described,  or  from  the  extension 


270  PROGNOSIS   OF 

of  diseased  action  to  the  brain  and  its  membranes,  and 
the  development  of  incurable  cerebral  disease. 

I  have  purposely  used  the  words  '^  progressive  ame- 
lioration," for  this  reason,  that  it  often  happens  in  these 
cases  that  under  the  influence  of  change  of  air,  of  scene, 
etc.,  a  temporary  amelioration  takes  place — the  patient 
being  better  for  a  time  at  each  new  place  that  he  goes 
to — or  under  every  new  plan  of  treatment  that  he 
adopts.  Fallacious  hopes  are  thus  raised  which  are 
only  doomed  to  disappointment,  the  patient  after  a 
week  or  two  relapsing,  and  then  falling  below  his  former 
state  of  ill-health. 

In  forming  an  opinion,  then,  as  to  the  patient's 
probable  future  state,  it  is  of  less  importance  to  look 
to  the  immediate  or  early  severity  of  the  symptoms 
than  to  their  slow,  progressive,  and  insidious  develop- 
ment. Those  cases  are  most  likely  to  be  permanently 
injured  in  which  the  symptoms  affect  the  latter  course. 

The  time  that  the  symptoms  have  lasted  is  neces- 
sarily a  most  important  matter  for  consideration.  When 
they  have  been  but  of  short  duration,  they  may  pos- 
sibly be  dependent  on  conditions  that  are  completely, 
and  perhaps  easily,  removable  by  proper  treatment,  as, 
for  instance,  on  extravasation  of  blood,  or  on  acute 
serous  inflammatory  effusion.  But  when  the  symptoms, 
however  slight  they  may  be,  have  continued  even  with- 
out progressive  increase,  but  have  merely  remained 
stationary  for  a  lengthened  period  of  many  months, 
they  will  undoubtedly  be  found  to  be  dependent  on 
those  secondary  structural  changes  that  follow  in  the 
wake  of  inflammatory  action,  and  that  are  incompatible 
with  a  healthy  and  normal  function  of  the  part.  I 
have  never  known  a  patient  to  recover  completely  and 
entirely,  so  as  to  be  in  the  same  state  of  health  that  he 
enjoyed  before  the  accident,  in  whom  the  symptoms 
dependent  on  chronic  inflammation  of  the  cord  and  its 
membranes,  and  on  their  consecutive  structural  lesions, 
had  existed  for  twelve  months.  Such  a  patient  may 
undoubtedly  considerably  improve,  but  he  will  never 
completely  lose  the  traces  of  the  injury.  These  will  in 
some  respects  be  permanent,  and  show  themselves  in 


CONCUSSION   OF  THE   SPINE.  27 1 

general  or  local  weakness,  loss  of  muscular  power, 
change  in  character,  various  head  symptoms,  each 
trivial  in  itself,  but  collectively  important ;  a  cachectic 
and  prematurely  aged  look,  and  digestive  derangement. 
And  though,  as  Ollivier  has  observed,  such  a  patient 
may  live  for  fifteen  or  twenty  years  in  a  broken  state  of 
health,  the  probability  is  that  he  will  die  in  three  or 
four.  ^  There  is  no  structure  of  the  body  on  which  an 
organic  lesion  is  recovered  from  with  so  much  difficulty 
and  with  so  great  a  tendency  to  resulting  impairment 
of  function  as  that  of  the  spinal  cord  and  brain  ;  and 
with  the  single  exception,  perhaps,  of  the  eye,  there  is 
no  part  of  the  body  on  which  a  slight  permanent  change 
of  structure  produces  such  serious  impairment  and  dis- 
turbance of  function  as  on  the  spinal  cord. 

The  cases  in  which  complete  recovery  may  be 
expected  are  those,  then,  in  which  the  patient  is  young, 
in  which  the  symptoms  have  been  the  effect  of  direct 
injury ;  in  which  they  have  rapidly  attained  their 
maximum  of  severity;  in  which  early  and  continuous 
amelioration  has  taken  place  ;  in  which  they  are  refer- 
able to  strain  of  the  ligaments  of  the  spine  and  to 
the  muscles  of  the  back  ;  to  irritation  of  the  nerves 
in  their  exit  from  the  vertebral  canal  ;  to  lesion  of 
nerve-trunks  rather  than  of  cerebral  mischief;  and, 
above  all,  to  extravasation  of  blood  into,  or  to  irrita- 
tion of  the  meninges,  rather  than  a  direct  primary 
lesion,  or  to  secondary  structural  change  of  the  cord 
itself. 

In  those  cases,  also,  In  which  the  emotional,  the 
hysterical,  or  the  hypochondriacal  element  has  from 
the  first  been  largely  associated  with  the  signs  of  special 
or  local  lesion,  a  very  favorable  prognosis  may  be 
given,  and  a  speedy  restoration  to  health  usually  pre- 
dicted, the  more  so  when  the  associacions  attendant  on 
litigations  are  removed,  which  in  these  cases  exercise 
an  important  influence  in  depressing  the  mental  and 
moral  tone  of  the  patient,  and  thus  materially  tending 
to  perpetuate  his  despondent  and  nervous  condition. 

I  may  take  this  opportunity  of  discussing  a  cjuestion 
which,  though  it  has  no  direct  bearing  upon  the  diag- 


2/2  PROGNOSIS   OF 

nosis,  or  even  on  the  prognosis,  of  these  injuries,  fre- 
quently springs  out  of  the  consideration  of  these  points 
in  the  case ;  I  mean  the  discrepancy  of  opinion  that 
frequently  arises  amongst  medical  men,  and  which 
develops  itself  in  the  evidence  given  in  courts  of  law, 
when  these  cases  of  alleged  spinal  injury  and  nervous 
shock  become  the  subject  of  judicial  investigation. 

That  conflicts  of  opinion  as  to  the  relations  between 
apparent  cause  and  alleged  effects ;  as  to  the  signifi- 
cance and  value  of  particular  symptoms,  and  as  to  the 
probable  result  or  prognosis  of  any  given  case,  must 
always  exist,  there  can  be  no  doubt.  And  this  is  more 
likely  to  happen  when  the  assigned  cause  of  the  evil 
appears  to  be  trifling ;  when  the  primary  effects  of  the 
injury  are  slight ;  when  the  secondary  phenomena 
develop  themselves  so  slowly  and  so  insidiously  that  it 
is  often  difficult  to  establish  a  continuous  chain  of  con- 
nection between  them  and  the  accident.  Such  dis- 
crepancy of  opinion  is  in  these  complicated  cases  not 
only  inevitable,  but  legitimate  ;  and  for  the  conflict  of 
views  to  which  it  leads  in  medical  evidence — when 
these  views  have  relation  to  matters  of  opinion  only, 
and  not  to  matters  of  fact — much  and  very  undeserved 
blame  has  been  cast  on  medical  witnesses. 

It  is  important  to  observe  that  it  is  not  as  to  the 
recognition  of  facts,  objective  symptoms,  or  positive 
signs  that  are  presented  in  any  given  cases  of  injury, 
when  the  physical  lesion  is  distinct ;  but  it  is  in  the 
inferences  to  be  drawn  as  legitimate  deductions  from 
these  facts,  that  conflict  of  opinion  and  discrepancy  in 
evidence  may  occasionally  arise ;  and  I  have  no  hesita- 
tion in  saying  that  in  at  least  nine-tenths  of  all  the  rail- 
way or  other  accidents  that  are  referred  to  surgeons  of 
experience  for  arbitration  or  advice,  there  is  not  only 
no  serious  difference  of  opinion  as  to  the  true  nature  of 
the  injury  sustained,  and  none  even  as  to  its  probable 
resulting  effects  on  the  patient  locally  or  constitution- 
ally, immediately  or  remotely.  But  in  a  certain  small 
percentage  of  cases  in  which  it  may  not  always  be  easy 
to  establish  to  demonstration  the  relation  between  the 
alleged    cause   and  the   apparent  effect,   in   which   the 


CONCUSSION   OF   THE   SPINE.  273 

symptoms  come  on  slowly  and  insidiously,  or  where 
they  may  possibly  be  referable  to  constitutional  or 
local  conditions  quite  irrespective  of  and  antecedent  to 
the  alleged  injury,  and  in  which  the  ultimate  result  is 
necessarily  most  doubtful,  being  dependent  on  many 
modifying  circumstances ;  in  such  cases,  I  say,  dis- 
crepancy of  professional  opinion  may  legitimately,  and 
indeed  must  necessarily,  exist.  There  is  no  fixed  stand- 
ard by  which  these  points  can  be  measured.  Each  sur- 
geon will  be  guided  in  his  estimate  of  the  importance  of 
the  present  symptoms,  and  of  the  probable  future  of 
the  patient,  by  his  own  individual  experience  of  pre- 
conceived views  on  these  and  similar  cases.  But,  in 
these  respects,  such  cases  differ  in  no  way  from  many 
others  of  common  and  daily  occurrence  in  medical  and 
surgical  practice.  We  daily  witness  the  same  discrep- 
ancies of  opinion  in  the  estimate  formed  by  professional 
men  of  the  nature  and  the  future  of  obscure  cases  of 
any  kind.  In  cases  of  alleged  insanity,  in  the  true 
nature  and  probable  cause  of  many  complicated  ner- 
vous affections,  in  certain  insidious  and  obscure  forms 
of  cardiac,  pulmonary,  and  abdominal  disease  ;  in  such 
cases  as  these  we  constantly  find  that  "  quot  homines 
tot  senteittice''  still  holds  good.  Even  in  the  more 
exact  science  of  chemistry,  how  often  do  we  not  see 
men  of  the  greatest  experience  differ  as  to  the  value  of 
any  given  test,  as  to  the  importance  of  any  given 
quantity  of  a  mineral, — as  of  arsenic,  mercury,  or 
antimony,  found  in  an  internal  organ — as  an  evidence  of 
poisoning. 

There  are  in  fact  two  questions  usually  presented  to 
the  surgeon  in  these  cases,  the  answers  to  which  stand 
in  very  different  categories  ;  one  being  capable  of  a 
positive  reply,  the  other  being  usually  open  to  doubt. 
The  first  question  is  as  to  the  value  of  any  one  symp- 
tom or  group  of  symptoms  as  indicative  of  the  fact  of 
the  occurrence  of  injury.  The  second  is  that,  admitting 
the  injury,  what  will  be  the  probable  duration  of  the 
evils  entailed  by  it,  and  will  the  ultimate  result  be  a 
complete  cure  or  only  partial  recovery  ?  Now,  except 
in  some  peculiarly  obscure  aiul  complicated  cases,  in 
18 


d 


274  PROGNOSIS   OF 

which  the  actual  state  is  rendered  uncertain  by  previous 
diseases  or  injuries,  there  cannot  be,  and  in  practice 
there  is  not,  any  possibility  of  a  conflict  of  opinion  in 
the  answer  to  the  first  q-uestion,  which  relates  simply  to 
matters  of  fact. 

But  it  is  in  reference  to  the  second  point  that  the 
conflict  of  opinion  so  often  arises.  Here  we  have  not 
a  question  of  fact  to  be  decided  by  observation.  We 
have  not  even  a  question  as  to  the  absolute  or  relative 
value  of  the  facts  so  observed,  but  we  have  to  draw- 
inferences  from  facts  the  existence  of  which  is  disputed 
or  perhaps  only  partially  admitted.  Even  if  the  surgeons 
are  fully  agreed  as  to  the  facts  of  the  injury — its  cause, 
its  nature,  or  the  reality  of  the  symptoms,  the  real  dif- 
ficulty— the  stumbling-block — then  presents  itself, which 
is  as  to  the  probable  future,  for  they  are  required  to  enter 
on  the  debateable  land  of  prophecy,  to  form  part  of  the 
genus  irritabile  vattiin,  and  to  forecast  the  patient's 
future.  They  are  asked  to  speak,  and  often  requested 
to  speak  positively,  in  reply  to  the  questions,  on  which 
it  is  impossible  to  dogmatize,  viz.,  whether  the  recovery 
will  be  partial  or  complete ;  and  further  than  this,  if 
partial  only,  then  to  what  extent?  If  complete,  then 
at  what  period  ?  Here  a  difficulty  at  once  arises 
which  is  felt  throughout  the  whole  domain  of  patho- 
logy. These  are  questions,  the  difficulty  in  answer- 
ing which  is  by  no  means  confined  to  the  compli- 
cated injuries  of  the  nervous  system,  but  extends  to 
the  simplest  cases  in  surgery  and  in  medicine.  Thus, 
for  instance,  a  man  breaks  his  leg  close  to  the  ankle- 
joint.  No  difference  of  opinion  does,  or  probably  can, 
exist  as  to  the  cause  of  the  injury,  its  nature  and 
extent ;  but  if  asked  to  give  a  dogmatic  opinion  as  to  the 
future  condition  of  that  man's  limb — if  he  will  ever 
recover  so  as  to  be  able  to  use  it  as  well  as  before  it  was 
injured,  and  if  so,  how  long  it  will  be  before  he  can 
walk,  run,  and  jump  with  as  much  facility  and  safety 
as  before  the  accident?  Or,  if  he  will  not  wholly 
recover,  and  be  permanently  injured,  to  what  extent  that 
permanent  injur}^  may  interfere  with  his  activity,  so 
that  though  he  may  be  able  to  walk,   whether  he  will 


CONCUSSION   OF   THE   SPINE.  275 

be  able  to  run  ;  and  if  he  can  walk  and  run,  whether 
he  can  ever  jump  ?  How  can  it  be  possible  for  any 
surgeon  to  give  a  positive  answer  to  such  questions, 
and  still  less  for  any  body  of  men  to  agree  on  any 
answer,  except  that  it  would  be  impossible  to  reply 
with  any  degree  of  precision  to  questions  such  as  these. 
So  with  regard  to  an  injury  of  the  nervous  system. 
The  injury  is  admitted,  but  the  question  immediately 
comes.  Is  this  injury  temporary  or  permanent  ?  Are 
the  symptoms  dependent  on  it  referable  to  functional 
or  organic  lesion  ?  Admitting  that  strength  of  mind 
and  clearness  of  intellect  are  materially  impaired  or 
dimmed,  when  will  they  be  restored  ?  Admitting  that 
the  patient  cannot  think,  read,  or  calculate  as  he  was 
accustomed  to  do  before  the  accident,  when  will  he  be 
able  to  do  so  as  clearly,  as  continuously,  and  as  cor- 
rectly as  before  he  was  injured?  Is  it  not  probable, 
nay,  is  it  not  inevitable,  that  in  the  answers  to  questions 
such  as  these,  differences,  and  possibly  conflicts,  of 
opinion  will  arise  ?  But  such  differences  are  inherent 
in  the  very  nature  of  the  subject.  They  are  not 
dependent  on  any  uncertainty  that  specially  pertains  to 
medicine,  but  on  the  impossibility  of  drawing  definite 
and  precise  conclusions  from  indefinite  premises.  It  is 
as  unreasonable  to  complain  of  the  uncertainty  of 
medical  science  because  such  questions  as  these  cannot 
be  answered  with  absolute  or  even  approximate  pre- 
cision, as  it  would  be  to  complain  of  the  uncertainty  of 
engineering  science  because  any  given  number  of  engi- 
neers might,  and  certainly  would  differ,  if  they  were 
required  to  say  how  many  miles  an  axle  with  a  flaw  in 
it  could  run  without  breaking  down.  The  truth  is,  that 
such  questions  cannot  be  answered  in  a  definite,  catego- 
rical, or  even  dogmatic  manner,  and  the  surgeon 
should  always  decline  to  give  a  positive  reply  to  a 
question  that  has  reference  to  the  possible  future  of  a 
case,  more  especially  when  the  element  of  time  is  asso- 
ciated with  that  of  recovery ;  when,  in  other  words,  he 
is  required  not  only  to  say  whether  the  patient  will  get 
well,  but  to  state  when,  or  still  worse,  to  say  when  he 
will  *'  be  sufficiently  recovered  to  attend  to  business." 


276  PROGNOSIS   OF 

Were  public  discrepancies  of  opinion  confined  to 
the  members  of  the  medical  profession  it  would  be  a 
lamentable  circumstance,  and  one  which  might  justly 
be  supposed  to  indicate  something  deficient  in  the 
judgment,  or  wrong  in  the  morale,  of  its  members 
But  when  we  look  around  us,  and  inquire  into  the 
conduct  of  members  of  other  professions,  we  shall  find 
that  in  every  case  in  which  the  question  at  issue  cannot 
be  referred  to  the  rigid  rules  of  exact  science — whether 
it  be  one  of  Engineering,  of  Law,  of  Pohtics,  or  of 
Religion — the  same  conflict  of  opinion  will  and  does,  as 
a  matter  of  necessity,  exist,  and  the  same  subjects  and 
the  same  phenomena  will  present  themselves  in  very 
varying  aspects  to  the  minds  of  different  individuals  — 
conflict  of  opinion  being  the  inevitable  result. 

Look  at  any  great  engineering  question.  Are  not 
engineers  of  the  highest  eminence  to  be  found  ranged 
on  opposite  sides  in  the  discussion  of  any  point  of  prac- 
tice that  has  become  one  of  opinion,  and  that  cannot 
be  decided  by  a  reference  to  those  positive  data  on 
which  their  science  is  founded  ?  Is  there  no  dis- 
crepancy of  opinion  often  manifested  among  gentlemen 
of  unimpeachable  integrity  in  their  profession,  as  to 
possible  causes  of  that  very  accident,  perhaps,  which 
has  occasioned  the  catastrophe  that  has  led  to  the  pres- 
ence of  the  surgeon  in  the  witness-box  ? 

Is  the  law  exempt  from  conflicts  of  opinion,  inde- 
pendently of  those  that  are  of  daily  occurence  in  its 
Courts?  Are  there  no  such  institutions  as  Courts  of 
Appeal  ?  Are  decisions  never  reversed  ?  Are  the  fif- 
teen Judges  always  of  one  mind  upon  every  point  that 
is  submitted  to  them  ?  Do  we  never  see  conflict  of 
opinion  spring  up  in  the  Lords  and  Commons,  amongst 
the  magnates  of  the  legal  profession,  on  questions  that 
involve  points  of  professional   doctrine  and  practice  ?  ''^ 

*"Reference  is  often  made  by  public  writers  to  the  conflict  of  opinion 
which  is  commonly  found  amongst  medical  witnesses.  Lawyers  are 
most  apt  to  refer  to  this  diversity  of  judgment — rarely  in  complimentary 
terms — most  often  to  su-gest  or  point  the  conclusion  that  judgments  so 
divided  in  their  course  and  so  little  consistent  are  of  slight  weight  and 
deserve  little  consideration.     A  barrister  furnishes  us  this  week  with 


CONCUSSION   OF  THE   SPINE.  27; 

Is  the  Church  herself  free  from  differences  of  the 
widest  kind  on  questions  that  we  are  taught  are  of  the 
most  vital  importance  ?  Have  we  not  for  years  past 
heard  questions  of  doctrine,  of  practice,  of  ritual,  dis- 
cussed with  an  amount  of  vehemence  and  zeal,  and 
with  a  conflict  of  opinion,  to  which  we  can  find  no 
parallel  in  our  profession?  Are  not  angry  passions 
roused  in  quarters  where  they  are  little  to  be  expected, 
and  may  we  not  at  times  be  tempted  to  exclaim, 
"  Tantcene  animis  coelestibiis  ircE  "  ? 

The  truth  is  that  these  conflicts  of  opinion  are 
common  to  all  the  professions  and  to  every  walk  of  life. 
Religion  and  Politics,  Law  and  Medicine,  and  the 
Applied  Sciences,  all  contain  so  much  that  is,  and  ever 
must  be,  matter  of  opinion,  that  men  can  never  be 
brought  to  one  dead  level  of  uniformity  of  thought 
upon  any  one  of  these  subjects ;  and  out  of  the  very 
conflicts  of  opinion  that  are  the  necessary  consequences 
of  the  diversity  of  views  that  are  naturally  entertained, 
Truth  is  at  last  elicited. 

Far  be  it  from  me  to  do  otherwise  than  to  speak 
with  the  utmost  respect  of  a  learned  and  liberal  pro- 
fession, when  I  say  that  slight  discrepancies  of  opinion 
arising  between   medical  men  are   often  magnified  by 


facts  that  should  modify  that  opinion,  if  strict  analogy  can  serve  to 
afford  an  illustration  or  to  point  an  argument.  The  analysis  of  the 
decisions  of  Lord  Justice  Giffard,  sitting  alone  in  appeal  cases  from  Jan- 
uary to  June  1870,  shows  that  of  forty-one  appeals  from  various  courts, 
the  decisions  of  those  courts  were  affirmed  in  seventeen  cases,  reversed  in 
nineteen  cases,  ai.d  varied  in  five  cases.  In  applying  this  illustration  to 
the  cases  of  difference  of  opinion  amongst  medical  experts  in  courts  of 
justice,  it  must  be  remembered  that  in  the  great  majority  of  cases  to  be 
decided — say  90  per  cent,  of  railway  compensation  cases — medical 
opinion  is  unanimous.  And  such  cases  do  not  come  into  court.  It  is 
only  where  doubts  and  difficulties  arise  that  a  judicial  decision 
in  court  is  ordinarily  asked.  The  cases  of  agreement,  which  are 
most  numerous,  are  settled  out  of  sight.  Moreover,  it  is  only- 
fair  to  take  into  account  the  essential  elements  of  mystery,  indi- 
vidual vital  differences,  and  special  combinations,  which  surround 
each  medical  case,  and  obstruct  the  arrival  at  certainty.  In  legal 
decisions,  all  the  conditions  are  known,  and  the  principles  to  be 
applied  are  ascertainable.  The  process  is  one  of  pure  reasoning,  free 
from  conjecture.  Yet  it  does  not  seem  to  be  productive  c  f  complete 
unanimity  in  the  end." — British  Medical  Joiannl,  June  18,  1870. 


2;8  PROGNOSIS  OF 

the  ingenuity  of  advocates,  so  as  to  be  made  to  assume 
a  very  different  aspect  from  that  which  they  were 
intend  to  present,  and  are  exaggerated  into  proportions 
which  those  who  propounded  them  never  meant  them 
to  acquire.  Perhaps  we  are  often  ourselves  not  alto- 
gether blameless  in  respect  to  the  misapprehension  that 
may  arise.  We,  as  medical  men,  are  guilty  of  two 
errors  in  giving  our  evidence.  We  are  apt,  in  the  first 
place,  to  be  too  dogmatic  in  our  opinions  ;  and  secondly, 
too  inexact  or  too  technical  as  to  the  language  in 
which  we  convey  them,  and  in  which  we  state  our  facts. 
However  necessary  it  may  be  for  a  teacher  or  prac- 
titioner to  assume  a  dogmatic  tone  in  order  to  press 
home  a  truth  on  a  class  not  over  attentive,  or  on  a 
patient  not  too  willing,  it  is  well  to  avoid  an  exhibition 
of  this  quality  in  a  court  of  law.  So  also  it  is  well  to 
avoid  the  use  of  technical  or  scientific  language  for  the 
expression  of  facts  that  can  be  stated  in  plain  English. 
The  same  words  or  modes  of  expression  that  would  be 
not  only  intelligible,  but  would  convey  a  very  definite 
meaning  with  them  in  the  discussions  of  a  medical 
society,  would  be  misunderstood  or  prove  confusing  to 
a  jury  unacquainted  with  medical  phraseology.  Techni- 
cal language  puzzles  and  confuses,  but  does  not  con- 
vince, and  medical  men,  in  the  statement  of  facts  as 
well  as  in  the  expression  of  opinions,  cannot  be  too 
careful  in  the  use  of  it.  But  not  only  is  it  necessary  to 
avoid  being  too  technical,  the  medical  witness  should 
endeavor  to  express  himself  as  succinctly  and  as 
clearly  as  possible.  We  deal  habitually  with 
the  material  rather  than  the  ideal,  with  facts 
rather  than  with  words,  and  are  frequently 
somewhat  inexact  in  the  expressions  we  use. 
Mere  verbal  differences,  mere  diversities  in  modes  of 
expressing  the  same  thing,  are  thus  sometimes  twisted 
into  the  semblance  of  material  discrepancies  of  state- 
ment and  opinion.  How  often  have  I  heard  in  courts 
of  law  attempts  made  to  show  that  two  surgeons  of 
equal  eminence  did  not  agree  in  their  opinions  upon 
the  case  at  issue,  because  one  described  a  limb  as  being 
"  paralytic,"  whilst  the  other  perhaps  said  ''  there  was  a 


CONCUSSION  OF   THE   SPINE.  2^9 

loss  of  nervous  and  muscular  power  In  It," — when  one 
said  that  the  patient  "  dragged  "  a  Hmb,  the  other  that 
he  "  walked  with  a  certain  awkwardness  of  gait."  The 
obvious  professional  moral  to  be  deduced  from  this 
is,  that  it  is  impossible  for  you  to  be  too  precise  in  the 
wording  of  your  expressions  when  giving  evidence  on 
an  obscure  and  Intricate  question.  However  clear  the 
fact  may  be  to  your  own  minds,  remember  that  It  may 
not  be  so  obvious  to  others  who  do  not  possess  the  pecu- 
liar technical  knowledge  that  you  have  acquired.  If  it 
be  stated  obscurely,  or  in  terms  that  admit  of  a  double 
interpretation,  you  may  be  sure  that  the  subtle  and 
practised  skill  of  those  astute  masters  of  verbal  fence 
who  may  be  opposed  to  you,  will  not  fail  to  take  advan- 
tage of  the  opening  you  have  inadvertently  given  them, 
to  aim  a  fatal  thrust  at  the  value  of  your  evidence. 
And  indeed,  the  expression  that  Is  In  itself  perfectly 
definite,  and  that  admits  of  no  ambiguity  In  the  mind 
of  a  medical  man,  may  present  a  very  different  meaning 
to  one  who  does  not  possess  the  requisite  amount  of 
anatomical  or  pathological  knowledge  to  be  able  cor- 
rectly to  appreciate  its  true  purport.  Thus,  for  instance, 
the  word  "  spine  "  is  used  by  an  anatomist  as  signifying 
only  the  column,  whereas  a  non-medical  man  will 
usually  employ  it  as  including  the  cord  as  well  as  its 
enclosing  case.  In  doing  so,  let  me  advise  you  to  confine 
yourselves  as  strictly  as  possible  to  answering  concisely 
and  Intelligibly  the  question  put  to  you.  It  is  seldom 
desirable  to  volunteer  statements  of  your  own.  When 
you  find  It  necessary  to  do  so  In  order  to  make  your 
answer  more  clear,  or  to  explain  away  any  misconcep- 
tion that  may  arise  as  to  your  meaning,  you  must  not 
do  so  until  after  you  have  answered  the  question  put 
to  you.  Answer  first,  explain,  if  necessary,  afterwards. 
But  let  me  advise  you  to  have  recourse  as  little  as 
possible  to  Independent  statements  and  unasked-for 
explanations.  Your  doing  so  may  place  you  in  a  wTong 
position,  In  that  of  an  advocate  rather  than  of  a  witness. 
It  is  impossible  to  impress  upon  you  too  strongly  how 
very  Important  It  Is  not  only  that  you  should  not  be  a 
partisan  In  the  case,  on  one  side  or  the  other,  but  that 


28o  PROGNOSIS  OF 

you  should  not  appear  to  be  so.  It  is  the  duty  of  a 
medical  witness  above  all  others  to  assist  the  court 
in  a  thoroughly  unbiassed  spirit  and  straightforward 
manner,  without  reference  to  the  side  on  which  he  has 
been  called.  A  medical  witness  is  not  retained  to  advo- 
cate the  cause  of  either  plaintiff  or  defendant.  It  is 
his  duty  to  give  a  truthful  and  clear  description  of  the 
facts  that  he  has  observed,  and  to  the  best  of  his  ability 
an  unprejudiced  opinion,  founded  on  the  inferences  that 
he  draws  from  these  facts.  It  is  the  business  of  the 
advocate,  and  not  that  of  the  medical  witness,  to  place 
the  cause  of  his  client  in  the  best  possible  light  by  sifting 
the  accuracy  of  the  facts  deposed  to,  and  to  elicit  the 
truth  by  questioning  the  validity  of  the  opinions 
expressed. 

There  is  a  very  important  difference  in  the  prognosis 
of  spinal  and  cerebral  affections,  according  as  they 
arise  from  disease  or  injury.  Hence  a  very  different 
estimate  of  the  duration  and  gravity  of  such  affections 
is  apt  to  be  entertained  by  the  physician  and  the 
surgeon.  When  a  given  train  of  spinal  or  cerebral 
symptoms,  whether  acute  or  slowly  progressive,  is  the 
result  of  disease,  it  is  invariably  indicative  of  structural 
changes  in  the  cord  or  brain ;  possibly  of  an  incurable 
and  probably  of  a  progressive  character,  due  to  failure 
of  nutrition,  as  in  atheroma  of  the  nutrient  arteries,  or 
to  remote  visceral  disease,  as  of  the  kidneys  or  heart. 

When  the  same  spinal  or  cerebral  symptoms  are  the 
result  of  injury — the  whole  of  the  evil  is  often  produced 
at  once — there  will  in  time  be  a  tendency  to  repair 
rather  than  to  degeneration,  and  the  patient  is  probably 
otherwise  perfectly  healthy. 

The  difference  in  the  importance  of  the  same  symp- 
tom, according  as  it  is  the  result  of  progressive  degen- 
eration or  of  sudden  injury — as  it  arises  from  what 
may  be  termed  a  medical  or  from  a  surgical  cause — is 
well  illustrated  by  Paraplegia.  If  this  condition  arise 
spontaneously,  it  is  probably  due  to  softening  and  de- 
generation of  the  cord,  and  will  be  incurable.  If  it 
be  the  result  of  injury,  it  may  be  owing  to  hsemorrhage 
into  the  spinal  canal,  and  will  disappear  as  the  blood  is 


CONCUSSION   OF   THE    SPINE.  28 1 

absorbed.  So  with  Unconsciousness.  This  condition, 
however  transitory,  occurring  suddenly  independent  of 
injury,  is  justly  regarded  by  the  physician  as  a  symp- 
tom of  the  gravest  import,  probably  of  an  epileptic 
nature.  Trousseau,  indeed,  regards  unconsciousness 
without  convulsions,  the  ''  petit  mal,"  as  more  serious 
than  the  major  epileptic  seizure  with  convulsions.  But 
the  same  importance  cannot  be  attached  to  it  when 
it  follows  a  head-inj_ury.  I  do  not  speak  only  of  the 
unconsciousness  which  occurs  at  the  moment  of  the 
concussion  of  the  brain,  but  of  that  occasional  attack  of 
momentary  loss  of  consciousness  which  may  ensue  at  a 
later  period.  Serious  as  this  symptom  undoubtedly  is, 
and  partaking  as  it  doubtless  does  of  the  epileptoid 
character,  it  stands  in  a  totally  different  category,  so  far 
as  the  future  of  the  patient  is  concerned,  to  that 
occupied  by  the  "  petit  mal."  It  is  not,  like  it,  progressive 
or  destructive  of  mental  vigor  and  capacity,  but  may, 
and  most  probably  will,  ultimately  disappear  without 
leaving  any  impairment  of  intellectual  power.  These 
examples  might  easily  be  multiplied.  But  what  I  have 
given  will  suffice  to  direct  attention  to  one  cause  of  that 
conflict  of  opinion,  well  known  in  the  prognosis  of  a 
case,  which  is  often  observed  between  physicians  and 
surgeons,  due  to  one  class  of  practitioners  being  accus- 
tomed to  see  a  particular  set  of  symptoms  develop  as 
the  result  of  pathological  lesion,  and  leading  to  dis- 
organization of  structure  ;  the  other  observing  them  as 
occasioned  by  injury,  and  tending  to  repair  of  tissue. 

Inequality  of  knowledge  will  certainly  cause  conflict 
of  opinion.  He  who  is  content  with  the  knowledge  of 
the  pathology  of  the  nervous  system  as  it  existed 
twenty,  fifteen,  or  even  ten  years  ago,  cannot  appreciate, 
and  hence  cannot  coincide  with,  views  founded  on  the 
more  advanced  and  more  accurate  investigation  of  its 
diseases,  and  a  clearer  insight  into  the  physiology  of 
the  brain  and  cord.  But  even  between  men  equally 
well  informed,  conflicts  of  opinion  are  on  certain  points 
not  only  unavoidable,  but  perfectly  legitimate,  and 
reflect  no  discredit  either  on  the  science  of  medicine  or 
on  those  who  entertain  conflicting  views.     On  the  con- 


282  PROGNOSIS   OF 

trary,  such  conflicts  of  opinion  may  be  looked  upon  ai^ 
highly  creditable  to  the  independence  of  thought  and 
the  individual  self-reliance  that  characterize  professional 
opinion  at  the  present  day. 

The  conflict  of  medical  evidence  often  arises  in  con- 
sequence of  a  want  of  proper  understanding  between 
the  medical  men  engaged  on  the  opposite  sides  of  the 
case.  As  matters  are  now  arranged,  there  is,  as  I  have 
already  shown,  no  "consultation,"  in  the  proper  sense 
of  the  word,  between  them.  The  surgeon  of  the  com- 
pany examines,  it  is  true,  the  plaintiff  before,  and  in 
the  presence  of  his  (the  plaintiff's)  own  medical  men ; 
but  there  is  no  after-discussion  of  the  case,  no  attempt, 
as  in  an  ordinary  consultation,  to  reconcile  discordant 
views,  and  to  come  to  a  combined  opinion  on  the  case. 
Neither  party  knows  the  exact  views  of  the  other  on 
any  point,  or  on  the  value  of  any  one  symptom,  until 
they  are  heard  in  court.  This  is  a  great  evil,  and  might 
be  corrected  by  the  surgeons  on  the  two  sides  meeting 
as  ordinary  consultants  discussing  the  case  together, 
and,  if  possible,  drawing  up  and  signing  a  conjoint 
report.  If  such  a  report  could  be  obtained,  it  might  be 
handed  mi  for  the  guidance  of  the  judge  and  counsel, 
and  the  strictly  medical  part  of  the  case  would  be  much 
simplified.  In  fact,  it  would  be  disposed  of  if  all  parties 
concerned  had  substantially  agreed  before  the  trial  as 
to  the  nature,  extent,  and  probable  duration  of  the 
plaintiff's  injuries  and  their  consequences,  the  tripod 
on  which  the  medical  question  always  rests.  In  the 
event  of  there  being  such  discrepancy  of  opinion  that 
an  agreement  could  not  be  come  to  on  any  or  all  of 
these  points,  the  judge  should  appoint  at  least  two 
surgeons  of  known  character,  and  of  recognized  skill  in 
the  particular  class  of  injury  under  consideration,  to 
draw  up  a  report  upon  the  plaintiff's  past  and  present 
condition  and  future  prospects.  This  report  would 
serve  to  guide  the  Court  in  coming  to  an  opinion  on 
the  purely  surgical  part  of  the  case,  and  afford  it  that 
information  which  men  who  admittedly  know  little  of  a 
subject  on  which  they  are  to  decide  must  necessarily  be 
supposed  to  wish  to  obtain.     The  experts  or  assessors 


CONCUSSION   OF  THE   SPINE.  283 

who  draw  up  this  report  should  be  appointed  by  the 
Court,  and  not  by  the  Htigants.  Their  position  would 
consequently  be  an  independent  one.  They  could  not 
be  accused  of  unworthy  motives.  They  could  not  be 
calumniated,  and  their  evidence  would  not  be  disparaged 
by  groundless  charges  of  partisanship. 

The  report  of  such  surgical  assessors  would  neces- 
sarily be  final.  It  could  scarcely  be  successfully  dis- 
puted by  those  medical  witnesses  from  whose  conclu- 
sions it  differed.  Hence  it  would  be  of  paramount 
importance  that  none  should  be  selected  for  such  an 
important  post  as  that  of  assessor  who  was  not  recog 
nized  as  possessing  not  only  a  sound  general  knowledge 
of  surgery,  but  such  special  experience  in  the  diseases 
resulting  from  injuries  of  the  cord  and  brain,  as  to  ren- 
der his  opinion  worthy  of  all  consideration  in  the  eyes 
of  his  professional  brethren.  Such  a  plan  would  not 
interfere  with  the  present  machinery  of  the  courts. 
The  case  would  continue  to  be  tried  in  the  ordinary 
common  law  courts,  before  a  jury  who  would  decide  on 
all  its  facts.  Their  judgment,  and  that  of  the  Court, 
would  be  guided  in  all  matters  of  scientific  opinion 
either  by  a  conjoint  surgical  report,  or,  if  that  cannot 
be  arrived  at,  by  the  written  statement  of  competent 
surgical  assessors,  who,  having  had  free  access  to  the 
plaintiff  and  to  the  medical  reports  on  both  sides,  could 
arrive  at  a  definite  and  unbiassed  conclusion  as  to  the 
nature,  extent,  and  probable  duration  of  his  injuries 
and  their  consequences.  It  would,  I  venture  to  sub- 
mit, be  in  the  highest  degree  advantageous  to  the 
medical  as  well  as  the  legal  profession.  The  great 
inconvenience  of  the  system  of  indiscriminately  sub- 
poenaing medical  practitioners  who  are  but  little  con- 
cerned in  the  case  would  be  stopped ;  conflict  of  medi- 
cal evidence  would  no  longer  occur.  Engendered  as  it 
is  partly  by  the  want  of  proper  understanding  between 
the  medical  witnesses,  and  greatly  encouraged  by  the 
want  of  due  scientific  knowledge  on  the  part  of  the 
Court,  it  would  not  survive  the  necessity  of  both  parties 
either  making  a  conjoint  report  or  submitting  their 
differences  of  opinion  to  the  arbitrament  of  skilled  sur- 


284  TREATMENT   OF 

gical  assessors  selected  by  the  Court.  And,  lastly,  the 
ends  of  justice  would  be  attained  with  more  certainty 
than  they  often  are  under  the  present  system. 

The  conclusions  that  may  be  drawn  from  the  fore- 
going observations  are  as  follows  : — 

1.  That  a  serious  hardship  is  inflicted  on  medical  men 
by  the  present  system  of  uselessly  multiplying  medical 
witnesses  in  compensation  cases. 

2.  That  much  evil  results  from  the  want  of  adequate 
scientific  and  technical  knowledge  on  the  part  of  the 
Court. 

3.  That  the  Court  should  be  assisted  by  assessors  of 
known  skill  and  experience  in  surgery. 

4.  That  such  assessors  should  be  appointed  by  the 
Court,  and  not  by  the  litigants. 

5.  That  the  surgical  witnesses  on  both  sides  should 
be  required  to  meet  and  to  draw  up  a  conjoint  report 
on  the  case  before  the  trial  comes  on.  Such  report  to 
be  submitted  to  the  Court  for  its  guidance  in  the  medi- 
cal and  surgical  parts  of  the  case. 

6.  That  in  the  event  of  the  surgical  witnesses  being 
unable  to  agree  on  the  terms  of  such  a  report,  the  case 
be  referred  to  the  assessors,  who  will  report  to  the 
Court  on  the  nature,  extent,  and  probable  duration  of 
the  plaintiff's  injuries. 

7.  That  the  report  of  the  assessors  be  final.* 


LECTURE  XIV. 

ON   THE   TREATMENT   OF  CONCUSSION   OF  THE   SPINE. 

In  the  treatment  of  a  case  of  concussion  of  the  spine 
the  surgeon  must  bear  in  mind  that  he  has  not  to  do 
merely  with  an  ordinary  physical  lesion,  but  with  one 
that  influences  materially  the  moral  and  mental  con- 
dition of  the  patient,  and  the  symptoms  of  which  are 

*  See  Lancet,  vol.  i.  1878;  and  "  Surgical  Evidence  in  Courts  of  Law," 
by  the  Author  (Longmans,  1878). 


CONCUSSION   OF  THE   SPINE.  285 

in  turn  seriously  aggravated  by  that  very  moral  depres- 
sion which  it  has  engendered.  It  becomes,  therefore, 
a  most  difficult  problem  to  solve  how  to  combine  that 
treatment  which  the  injury  that  the  spine  has  sus- 
tained may  require  with  that  calculated  to  prevent,  or 
at  all  events  not  to  augment,  the  hypochondriacal  and 
hysterical  states  so  often  resulting  from  these  accidents. 

The  primary  and  immediate  treatment  of  a  case  of 
concussion  of  the  spine  presents  nothing  peculiar  or 
that  calls  for  special  attention.  The  moderate  admin- 
istrations of  diffusible  stimulants,  warm  drinks,  the 
repose  of  bed,  and  the  local  application  of  hot  fomen- 
tations, if  superficial  or  deep  pain  is  suffered,  comprise 
all  that  needs  be  done  in  these  cases. 

The  after-treatment  resolves  itself  into  means  for 
the  alleviation  or  cure  of  those  diseases  which  are  the 
more  remote  consequences  of  the  injury  sustained  by 
the  vertebral  column  and  its  contents,  or  of  the  shock 
to  which  the  nervous  system  has  been  subjected.  It 
includes  a  variety  of  therapeutic  means,  amongst  which 
rest,  counter-irritation,  electricity,  absorbent,  sedative, 
and  tonic  medicines  are  the  more  important. 

The  method  of  application  and  the  mode  of  adminis- 
tration of  these  various  local  means  and  constitutional 
remedies  present  nothing  that  is  in  any  way  special  in 
the  treatment  of  these  injuries. 

The  point  that  essentially,  and  at  last  must  guide  the 
surgeon  in  his  choice  of  remedies,  is  the  pathological 
condition  that  lies  at  the  bottom  of  the  secondary  dis- 
ease, induced  by  the  concussion  of  the  spine  or  the 
nervous  shock  to  which  the  patient  has  been  subjected. 
Is  this  sub-inflammatory,  of  the  nature  of  meningitis, 
myelitis,  or  meningo-myelitis  ?  or  is  it  the  very  reverse, 
indicative  of  exhaustion  or  anaemia  of  the  nervous 
centres  ?  It  is  obvious  that  the  determination  of  this 
point  is  of  the  first  importance,  and  that  the  treatment 
which  would  be  proper  and  beneficial  in  the  one  case 
would  be  in  the  highest  degree  improper  and  hurtful  in 
the  other.  Bearing  this  in  mind,  let  us  consider  more 
in  detail  the  different  means  that  we  adopt.  And  first 
with  regard  to  the  treatment  of  the  inflammatory  state. 


286  TREATMENT   OF 

Rest. — The  first  thing  to  be  done  in  a  case  of  injury 
of  the  spine  with  concussion  of  the  cord  is  undoubtedly 
to  give  the  injured  part  complete  rest.  But  rest  of  the 
spine  means  the  prone  or  recumbent  position  continu- 
ously maintained ;  complete  immobility  of  the  body, 
the  avoidance  not  only  of  walking  and  movement  of 
any  kind,  but  even  in  many  cases  of  standing  upright. 
It  entails,  consequently,  an  interruption,  often  a  long 
suspension,  of  all  the  ordinary  occupations  of  life. 
The  idleness  which  is  the  necessary  result  of  long-con- 
tinued enforced  rest  is,  however,  apt  to  act  injuriously 
on  the  mind,  more  especially  in  that  large  class  of  labor- 
ing or  of  active  business  men,  who  with  little  intellec- 
tual culture,  have,  in  illness,  no  mental  resources  to  fall 
back  upon,  their  lives  having  been  spent  from  boyhood 
in  a  hard  struggle  for  bare  subsistence,  or  in  the  absorb- 
ing pursuit  of  gain.  These  men,  who  are  amongst  the 
most  frequent  sufferers  by  railway  collisions,  truly 
*'  know  no  Paradise  in  rest,"  and  to  them  the  long-con- 
tinued monotony  of  a  sick  room  is  a  source  of  much 
mental  depression,  which  is  often  aggravated  by  the 
loss  of  the  means  of  sustenance,  and  by  the  corroding 
cares  of  the  res  angiistce  doini,  consequent  on  the  anni- 
hilation of  all  business  income.  The  consequences 
entailed  by  rest  thus  exercise  a  most  injurious  influence 
in  still  farther  depressing  the  moral  tone  and  mental 
elasticity  which  have  already  been  seriously  shaken  by 
the  effects  of  the  accident  for  which  repose  is  enjoined. 

But  notwithstanding  these  concomitant  and  una- 
voidable ills,  rest,  absolute  and  complete,  is  a  necessary 
preliminary  to,  and  accompaniment  of,  all  other  treat- 
ment in  every  case  of  injury  of  the  spine,  whether  from 
direct  violence,  strain,  or  wrench,  that  is  accompanied 
by  symptoms  of  concussion  of  the  cord,  and  above  all, 
by  those  of  meningo-myelitis. 

The  importance  of  rest  cannot  be  over-estimated  in 
these  cases.  Without  it  no  other  treatment  is  of  the 
slightest  avail,  and  it  would  be  as  rational  to  attempt 
to  treat  an  injured  brain  or  a  sprained  ankle  without 
repose,  as  to  benefit  a  patient  suffering  from  a  severe 
concussion  or  wrench  of  the  spine  unless  he  is  kept  at 


CONCUSSIOX  OF  THE  sriNE,  287 

rest.     In  fact,  owing  to  the  extreme  pain  in  movement 

that  the  patient  often  suffers,  he  instinctively  seeks  rest, 

and  is  disincHned  to  exertion  of  any  kind.     It   is  the 

more  important  to  insist  upon  rest  when,  however,  the 

cord  rather  than   the  column  is  injured,  for  not  unfre- 

quently  patients  feel  for  a  time  benefited  by  movement 

— by  change  of  air  and  of  scene.  And  hence  such  changes 

are  thought  to  be  permanently  beneficial.    But  nothing 

can  be  more  erroneous  than  this  idea,  for  the  patient 

will  invariably  be  found  to  relapse  and  to  fall  back  into 

a  worse  state  than  had  previously  existed.     The  truth 

is,  that  in  most  of  these  cases  of  spinal  concussion  there 

is  mental  disturbance  as  well  as  physical  derangement. 

New  scenes  benefit  the  mind  and  cheer  the  spirits,  but 

the  exertion  of  traveling  in  search   of  them,  and  the 

necessity  for  increased  bodily  exercise  are  most  injurious 

to   the   physical    state  and    tend  greatly  to  aggravate 

existing  spinal  irritation.     In  more  advanced  stages  of 

the_  disease,  when  chronic    meningitis    has    set  in,  the 

patient  suffers  so  severely  from    any,  even    the  very 

slightest  movement  of  the  body,  from  any  shock,  jar, 

or  even  touch,  that  he  instinctively  preserves  that  rest 

which  is  needed,  and  there  is  no  occasion  on  the  part 

of  the  surgeon  to  enforce  that  which   the  patient  feels 

to  be  of  imperative  necessity  for  his  own  comfort. 

In  order  to  secure  rest  most  efficiently,  the  patient 
should  be  made  to  lie  on  a  prone  couch.  There  are 
several  reasons  why  the-  prone  should  be  preferred  to 
the  supine  position.  In  the  first  place,  in  the  prone 
state  the  spine  is  the  highest  part  of  the  body,  and  thus 
passive  venous  congestion  and  determination  of  blood 
to  the  spinal  cord,  which  are  favored  and  naturally 
occur  when  the  patient  lies  on  his  back,  are  entirely 
prevented,  and  that  additional  danger  which  may  arise 
from  this  cause  is  averted  so  long  as  the  prone  position 
is  maintained.  Then  again,  the  absence  of  pressure 
upon  the  back  is  a  great  comfort  in  those  cases  in 
which,  in  consequence  of  injury  to  the  vertebral  column, 
it  is  unduly  sensitive  and  tender.  Lastly,  the  prone 
position  presents  this  advantage  over  the  supine,  that 
it  admits  of  the  application  of  any  necessary  treatment. 


288  TREATMENT   OF 

To  some  patients  the  prone  position  becomes  very 
irksome  and  cannot  long  be  borne.  It  then  becomes 
necessary  to  allow  them  to  lie  flat  on  the  back,  with 
the  head  slightly  raised.  There  is  this  peculiarity 
about  the  maintenance  of  the  supine  position  in  these 
cases, — that  the  danger  of  sloughing  of  the  back  is  but 
very  small.  It  is  remarkable,  indeed,  how  very  rarely 
this  occurs.  Hence  the  prone  position  is  not  necessary 
as  a  preventive  of  the  complication. 

The  vitality  of  the  paralyzed  parts  in  paraplegia 
from  concussion  of  the  spine  does  not  fall  so  low  as  it 
does  in  cases  of  compression  or  laceration  of  the  cord 
in  fractured  spine. 

Sloughing  from  pressure  upon  exposed  and  promi- 
nent parts,  which  is  so  common  in  paralysis  after 
fracture  of  the  spine,  does  not  occur  in  cases  of  loss 
of  power  from  spinal  concussion.  I  do  not  remember 
ever  to  have  seen  a  case  in  which  confinement  to  bed 
or  couch,  even  though  prolonged  for  many  months,  was 
followed  by  this  serious  and  often  fatal  consequence  of 
ordinary  traumatic  paraplegia.  In  fact,  in  all  these 
cases  of  concussion,  bedsore  may,  w^ith  the  most  ordi- 
nary care  and  attention  to  cleanliness,  and  relief  from 
pressure,  be  entirely  prevented. 

When  the  patient  begins  to  move  about,  equal  com- 
fort and  advantage  will  be  derived  from  the  use  of  the 
plaster  of  Paris  jacket,  the  poroplastic  jacket,  of  spinal 
stays,  or  a  gutta-percha  case,  to  embrace  the  shoulders, 
neck,  and  occiput,  and  support  the  back.  In  cases 
where  the  cervical  spine  alone  is  affected,  the  use  of  a 
stiff  collar  is  beneficial. 

But  if  rest  is  needed  to  the  spine,  it  is  equally  so  to 
the  brain.  I  have  repeatedly  in  these  Lectures  had 
occasion  to  point  out  the  fact  that  in  cases  of  concus- 
sion of  the  spine  the  membranes  of  the  brain  become 
liable  to  secondary  implication  by  extension  of  inflam- 
matory action  to  them.  The  irritability  of  the  senses 
of  sight  and  hearing,  that  is  so  marked  in  many  of 
these  cases,  with  perhaps  heat  of  the  head,  or  flushings 
of  the  face,  are  the  best  evidences  of  this  morbid 
action.     For  the  subdual  of  this  state  of  increased  cere^ 


CONCUSSION   OF   TlfE   SPINK.  289 

bral  excitement  and  Irritability,  it  is  absolutely  neces 
sary  that  the  mind  should  be  kept  as  much  as  possible 
at  rest,  and  that  disquieting  influences  and  emotions 
should,  as  far  as  practicable,  be  avoided.  The  patient, 
feeling  himself  unequal  to  the  fatigue  of  business, 
becomes  conscious  of  the  necessity  of  relinquishing  it, 
though  not  perhaps  without  great  reluctance,  and  not 
until  after  many  ineffectual  efforts  to  attend  to  it. 
Under  these  circumstances  the  brain  must  be  allowed 
to  lie  fallow  for  a  season.  It  is  seldom  necessary  to 
insist  on  this  absolute  rest  of  brain  in  one  who  suffers 
from  cerebral  irritation.  He  finds  it  simply  impossible 
to  employ  his  mind  on  any  subject  that  requires  an 
effort  of  the  intellect  or  the  strain  of  sustained  atten- 
tion, without  a  great  aggravation  of  his  sufferings.  But 
if  unable  to  occupy  himself  with  the  ordinary  business 
of  his  life,  care  must  be  taken  that  the  patient  do  not 
suffer  from  the  mental  inaction  and  fall  into  a  state  of 
melancholia  from  the  monotony  of  his  enforced  idleness; 
and  attempts  should  be  made  to  fill  up  the  vacant  hours 
by  recreation  of  some  sort. 

But  if  rest  is  thus  absolutely  necessary  in  cases  of 
meningitis  and  myelitis,  it  is  not  equally  so  in  those 
cases  of  spinal  anaemia,  which  so  closely  simulate  real 
organic  disease,  and  which  are  often  associated  with 
hysteria.  In  these  cases  the  patient  should  be  encour- 
aged to  move  about ;  to  be  much  in  the  open  air.  If 
unable  to  walk,  then  he  must  use  a  carriage  or  a  chair. 
But  anyway,  out-of-door  life  and  exercise  of  some  kind, 
though  to  a  limited  extent,  will  be  useful. 

Sleep. — Next  to  rest  it  is  most  important  to  endeavor 
to  secure  sleep  in  cases  of  concussion  of  the  spine. 
It  is  impossible  to  expect  that  the  nervous  system  can 
recover  itself  so  long  as  the  patient  passes  wakeful  nights, 
or  is  disturbed  by  horrible  dreams.  Unfortunately  in 
these  cases  narcotics  are  as  a  rule  not  well  borne.  The 
various  preparations  of  opium  and  morphia,  whether 
administered  by  the  mouth  or  given  hypodermically, 
are  not  only  seldom  successful  in  securing  rest  or  in 
allaying  pain,  but  are  often  positively  injurious,  at  least 
so  far  as  securing  sleep  is  concerned.  Chloral  hydrate 
19 


290  TREATMENT   OF 

is  more  advantageous  and  safer  than  the  opiates.  It 
should  be  given  in  tolerably  full  doses,  from  25  to 
40  grains,  either  at  once  or  divided  in  the  course  of 
the  night.  Next  to  the  chloral  hydrate,  and  especially 
in  those  cases  in  which  there  is  distinct  meningeal 
irritation,  the  bromides  are  of  great  service,  and 
indeed,  may  often  be  advantageously  combined  with  the 
chloral,  tranquillising  the  cerebral  irritation  whilst  the 
chloral  more  distinctly  induces  sleep. 

Local  applications. — The  local  treatment  to  be 
applied  to  the  spine  will  vary  according  as  we 
have  to  do  with  meningo-myelitis  or  anaemia  of  the 
cord. 

In  the  inflammatory  affection  in  the  early  stages, 
hot  fomentations,  leeching,  or  dry-cupping  will  be  of 
essential  service.  At  a  more  advanced  period  repeated 
blistering  will  be  found  to  give  great  relief.  I  have 
never  found  it  necessary  to  employ  issues  or  setons, 
but  if  there  is  evidence  of  disease  in  the  vertebral 
column  itself,  these  might  be  employed  with  advantage. 
The  pain  which  I  have  termed  sacrodynia  is  little 
influenced  by  ordinary  topical  agents.  The  only  means 
that  I  have  found  to  ensure  a  beneficial  influence  on  it 
have  been  active  stimulants  or  counter-irritants,  such 
as  blistering,  or  the  thermic  hammer. 

In  the  diffuse  hyperaesthesia  of  spinal  anaemia  the 
ice-bag  and  the  continuous  galvanic  currents  are  often 
useful.  In  these  cases,  also,  various  embrocations  of 
belladonna,  aconite,  camphor,  &c.,  will  be  found  to  allay 
pain  and  comfort  the  patient. 

In  the  more  advanced  stages  cold  salt-water  douches, 
or  the  shower-bath,  will  prove  serviceable. 

Medicines. — The  iodide  of  potassium  is  of  the  great- 
est value  in  all  those  cases  in  which  there  are  evidences 
of  chronic  or  subacute  meningitis.  It  should  be  given 
in  full  doses,  and  continued  for  a  considerable  length  of 
time.  It  may  be  well  to  commence  with  5  grains  three 
times  a  day,  and  to  carry  it  on  gradually  until  from  15 
to  20  are  given  for  a  dose.  It  is  particularly  in  cases 
of  muscular  cramps  or  stiffness  that  the  iodide  is  of 
service,  and  in  those  forms   of  fibroid  or  ligamentous 


CONCUSSION   OF  THE   SPINE.  29I 

tenderness  that  are  frequent  after  wrenches  of  the 
spine,  and  that  resemble  rheumatism. 

The  bromide  of  potassium  or  of  ammonium  is  useful 
in  relieving  the  cerebral  distress,  irritation,  or  pressure, 
that  is  so  frequently  complained  of  as  a  concomitant 
symptom  of  meningo-myelitis. 

The  employment  of  the  perchloride  of  mercury  in 
certain  forms  of  paraplegia  was  strongly  advocated  by 
Sir  Benjamin  Brodie  and  Dr.  Latham.  The  great  value 
of  this  remedy  and  of  the  iodide  of  potassium  is  univer- 
sally admitted  in  syphilitic  paralysis.  In  some  of  the 
traumatic  forms  of  paraplegia  the  use  of  the  perchloride 
is  equally  efficacious.  In  ordinary  idiopathic  paraplegia 
— in  those  forms  of  the  disease  that  arise  from  other 
than  traumatic  causes,  in  which  the  paralysis  is  rather 
due  to  nutritive  changes,  leading  to  softening,  to  disinte- 
gration, and  disorganisation  of  the  substance  of  the 
cord  itself  than  to  inflammatory  action  developed  in  an 
otherwise  healthy  person — mercurials  would  undoubt- 
edly be  injurious  rather  than  beneficial.  So  also  in 
spinal  anaemia  they  would  be  most  hurtful. 

But,  on  the  contrary,  in  those  traumatic  forms  of 
paraplegia  dependent  on  pressure  from  extravasated 
blood,  on  inflammation  of  the  meninges,  on  pressure  on 
the  cord  from  inflammatory  effusions,  the  perchloride 
of  mercury  is  undoubtedly  most  beneficial.  It  is  in 
similar  cases,  and  more  especially  in  the  more  marked 
cases  of  meningitis  of  a  sub-acute  character — those 
cases  in  which  there  Is  morbid  rigidity  and  contraction 
of  muscles,  that  Iodide  of  potassium  Is  so  markedly 
beneficial. 

Treatment  of  Spinal  AncEniia. — When  the  symptoms 
are  rather  those  of  spinal  anaemia  than  of  meningo- 
myelitis,  the  preparations  of  iron  and  strychine  will 
be  found  to  be  of  the  highest  value  ;  in  fact,  as  has 
already  been  stated  in  the  Lecture  on  Diagnosis,  the 
tolerance  or  not  of  strychnine  in  these  cases  will  serve 
as  a  therapeutic  test  of  considerable  value,  as  to 
whether  the  disease  be  one  of  spinal  exhaustion  or  of 
inflammation.  There  is  probably  no  better  method 
of  administering  these  remedies,  in  the  majorit}'  of  the 


292  TREATMENT   OF 

cases  that  I  have  mentioned  than  by  giving  a  pill 
three  times  a-day  containing  a  quarter  of  a  grain  of 
the  extract  of  nux  vomica  with  two  or  three  grains 
of  the  dried  sulphate  of  iron,  or  administering  them 
in  the  form  of  the  syrup  of  the  phosphates  of  iron, 
strychnine,  and  quinine.  But  the  precise  method  of 
administration  signifies  little,  it  is  the  principle  on  which 
I  wish  to  insist,  and  to  which  I  wish  to  direct  your 
attention,  that  you  must  treat  these  cases  of  spinal 
anaemia  by  means  of  strychnine  and  iron  in  some  shape 
or  another.  In  addition  to  this,  you  will  find  it  neces- 
sary to  insist  upon  a  liberal  allowance  of  good  food 
being  taken  with  wine  or  beer.  I  have  spoken  of  rest 
as  being  absolutely  necessary  in  those  cases  in  which 
there  is  meningo-myelitis ;  but  in  cases  of  spinal 
anaemia  it  is  desirable  that  the  patient  should  be  as 
much  as  possible  in  the  open  air,  carried  out,  laid  on 
a  mattress,  drawn  about  in  a  Bath  chair,  when  the 
season  permits.  The  monotony  of  the  seclusion  to  a 
bed-chamber  is  most  injurious.  Some  mental  occupa- 
tion should  be  insisted  upon ;  recovery  is  often  mate- 
rially retarded,  and,  indeed,  the  ill-effects  in  many  of 
these  cases  of  concussion  of  the  spine,  followed  by  an 
exhausted  state  of  the  nervous  system,  are  greatly 
increased  by  want  of  employment,  amusement,  or  men- 
tal distraction  of  some  kind.  The  patient  dwells  upon 
his  sufferings,  becomes  morbidly  sensitive  in  mind,  or 
melancholic  and  hypochondriacal.  These  mental  con- 
ditions are  especially  apt  to  develop  themselves  in  people 
of  active  business  habits,  with  few  intellectual  resources. 
Such  persons,  when  forced  to  lead  a  life  of  physical 
inactivity,  have  no  means  of  filling  up  their  time  and 
occupying  their  thoughts  by  intellectual  pursuits,  even 
of  a  very  simple  character  ;  and  it  is  in  them  especially 
that  a  forced  inactivity  exercises  so  very  prejudicial  an 
effect  in  retarding  or  altogether  preventing  recovery. 
It  is  in  these  cases  of  spinal  anaemia,  and  in  such 
individuals  especially,  that  change  of  scene  is  of  great 
benefit.  Injurious  as  traveling,  and  especially  a  resi- 
dence at  the  sea-side,  so  commonly  ordered  in  an 
inconsiderate  off-hand  manner  is  in  cases  of  meningo- 


CONCUSSION   OF  THE   SPINE.  293 

myelitis,  it  is  of  the  utmost  value  in  restoring  the  lost 
tone  to  the  nervous  system  in  cases  of  simple  exhaus- 
tion of  it. 

Exercise  is  not  advantageous  whilst  the  nervous 
system  continues  in  an  exhausted  or  enfeebled  state. 
Patients  suffering  from  spinal  anaemia  may  be  benefited 
greatly  by  change  of  air -and  change  of  scene,  their 
nutrition  improved  by  the  one  and  their  mental  tone 
invigorated  by  the  other  ;  but  they  are  not  improved  by 
being  subjected  compulsorily  to  exercise.  As  they 
recover  they  will  instinctively  and  proportionately  to 
the  return  of  strength  resume  their  habits  in  this 
respect. 

It  is  of  great  importance  to  keep  up  the  temperature 
of  the  body,  especially  of  the  extremities,  by  artificial 
means.  Unless  this  is  done  the  circulation  becomes 
retarded  in  the  cold  feet  and  hands  :  nutritive  changes 
are  ill-effected  ;  the  blood  is  cooled  down  in  traversing 
parts  the  temperature  of  which  is  many  degrees  below 
the  normal  point.  Carried  back  to  the  heart  in  this 
cooled-down  state,  it  tends  to  depress  its  action,  and 
thus  to  lower  the  force  of  the  circulation  throughout 
the  body,  and  proportionately  to  lessen  the  energy  of 
all  those  actions  dependent  upon  its  activity. 

Electricity  in  its  different  forms  is  of  extreme 
service  in  many  cases  of  spinal  anaemia  and  in  the 
removal  of  local  paralysis,  whether  it  be  connected  with 
this  condition,  be  the  remote  consequence  of  changes 
dependent  on  the  structural  lesions  of  the  cord,  or  the 
effect  of  local  injury  of  some  nervous  trunk. 

For  the  necessary  directions  to  guide  the  surgeon 
in  the  employment  of  electricity  in  these  various  cases, 
I  must  refer  to  the  works  of  Reynolds,  Althaus,  and 
Duchenne.  There  is  nothing  special  in  the  mode  of 
its  employment  in  traumatic  cases  that  deserves  par- 
ticular notice.  But  there  are  a  few  words  of  caution 
and  advice  that  I  may  give  you  with  respect  to  the 
class  of  cases  in  which  it  is  likely  to  be  beneficial  or 
hurtful. 

Faradisation  will  be  found  of  especial  service  in 
cases  of  simple  loss  of  nervous  power  without  an)   -^igns 


294  TREATMENT   OF 

of  concomitant  inflammation,  central  or  peripheral. 
Thus  it  will  be  found  of  great  use  in  the  paraplegia  of 
spinal  anaemia,  in  the  loss  of  power  in  the  extensors  of 
the  foot  and  toes  and  the  peronei  muscles  dependent 
on  paralysis  of  the  external  popliteal  nerve,  a  form  of 
paralpsis  that  has  frequently  been  referred  to  in  these 
lectures,  and  of  very  common  occurrence  after  spinal 
concussion  ;  and  lastly,  in  those  localised  forms  of  para- 
lysis of  the  upper  extremity  dependent  on  affection  of 
the  supra-scapular,  circumflex,  or  musculo-spiral  nerves. 

The  continuous  current  applied  to  the  spine  is  par- 
ticularly useful  in  spinal  anaemia  and  for  the  relief  of 
the  cutaneous  hyperaesthesia  associated  with  it. 

Electricity  in  any  shape  is  always  hurtful  when 
there  are  symptoms  of  subacute  inflammatory  action, 
especially  of  the  meningeal  form,  associated  with  the 
paralysis,  as  indicated  by  muscular  rigidity  or  painful 
cramp.  I  think  that  we  may  broadly  say  about  this 
therapeutic  rule  with  respect  to  the  employment  of  elec- 
tricity, that  it  is  useful  in  those  cases  that  are  benefited 
by  strychnine  and  iron  ;  whereas,  in  those  that  are  made 
worse  by  these  remedies,  electricity  is  equally  hurtful, 
in  fact,  the  injury  resulting  or  benefit  to  be  derived 
from  the  use  of  electricity  will  be  in  the  exact  ratio  of 
the  inflammatory  or  asthenic  character  of  the  paralysis. 

The  treatment  of  spinal  anaemia  may  be  summed 
up  in  a  very  fev/  words — a  cheerful  life,  plenty  of  fresh 
air,  sea  or  mountain,  well-ventilated  rooms,  repose  but 
not  solitude,  warm  sea-water  bathing  and  douching, 
skin-friction,  good  food,  iron,  quinine,  phosphorus,  and 
strychnine.  And  should  the  spine  be  tender,  repeated 
flying  blisters  to  the  painful  parts  ;  in  fact,  an  hygienic, 
dietetic,  and  medicinal  plan  of  treatment  of  a  tonic 
character. 

But  whatever  treatment  be  adopted,  no  speedy 
benefit  can  be  expected.  In  the  most  favorable  cases 
the  duration  of  the  spmptoms  will  have  to  be  counted 
by  months,  in  many  by  years.  For  the  health  may 
continue  permanently  broken,  or  some  local  nerve  lesion 
will  persist  in  spite  of  the  most  carefuf  treatment. 

When  the  case  involves  a  claim   for  compensation, 


CONCUSSION   OF  THE   SPINE.  ^93 

care  must  be  taken  to  see  that  the  treatment  prescribed 
is  properly  carried  out,  and  that  the  patient  does  not 
by  neglecting  it  and  nursing  his  symptoms  mislead  the 
surgeon  as  to  he  gravity  and  probable  persistence  of 
his  condition  and  the  inefficacy  of  treatment  in  reliev- 
ing it. 

The  treatment  of  various  local  ailments  consequent 
on  or  associated  with  the  spinal  injury  need  not  detain 
us,  as  it  must  be  conducted  on  general  medical  and 
surgical  principles. 


INDEX. 


ABERCROMBIE   on  injury  of 
spine,  2g,  71. 
Accidents,  railway,  nature  of,  18. 
Accommodation,      of      the      eye, 

changes  in,  147,  214. 
Accommodation,  failure  of,  216. 
Allbutt,    Dr.,     on    optic   neuritis, 

217. 
Amblyopia,  216. 
Anatomy,  morb'd,  160, 

in  meningo-myelitis,  162, 

' in  myelitis,  163. 

in     spinal     meningitis,    161, 

163. 
Ansemia,  spinal,  158,  168,  170. 
Anaesthesia,  62,  63,  97. 
and  hypersesthesia  in  opposite 

limbs,  98. 
Asthenopia,  147,  216. 
Astigmatism,  216. 
Attitude  in  spinal  injuries,  148. 

BELL,  Sir  Charles  on  spinal  in- 
jury, 28,  74,  76. 

Bladder,  atony  of,  67. 

contraction  of,  67. 

irritability  of,  155, 

Boyer  on  spinal  injuries,  29,  76. 

Brachial  plexus,  injury  of,  39. 

Brown-Sequard  on  motor  and  sen- 
sory tracts,  65. 

on  hereditary  transmission  of 

effects  of  injuries,  18. 

CARDIAC  debility,  191. 
Cataract,  208. 
Central   changes   after    peripheral 

injury,  201. 
Cerebral  symptoms,  139,  145,  165, 

257. 
Cervical  region,  injury  of,  56,  262. 
Cilio-spinal  axis,  221. 
Clarke,  Dr,  L.,  on  morbid  changes 

in  spinal  cord,  160. 


Coccydynia,  187. 

Coldness  of  extremities,  154,  172. 

Concussion  of  spine,  26. 

from  general  shock,  93. 

from  severe  direct  injury,  26. 

from  slight  or  indirect,  78. 

effects  of,  143. 

nature  of,  28,  143,  158. 

pathology  of,  157. 

Contraction   of   muscles,   87,    154, 

167. 
Convulsions,  36,  74. 
Cooper,  Sir  A.,  on    spinal  injury, 

28,  72. 
Cord,  spinal,  induration  of,  164, 

inflammation  of,  27,  76,   162. 

softening  of,  73,  77,  164. 

consultations,  282. 

Countenance  in  spinal  injury,  145. 

Cramp,  70. 

Crossing   of  nerve-fibres  in   cord, 

as- 
Crystalline    lens,    dislocation     of, 

208. 
Curvature  of  spine,  28,  63, 
Cystitis,  67. 

DEAFNESS,  147,  148. 
Death  after  spinal  injury,  48, 
50,  56,  71,  72,  100,  113. 
Death,  sudden,  54.  56. 
Diabetes,  200. 
Diagnosis,  79,  246. 
Diaphragm,  spasm  of,  87,  151 
Diplopia,  146,  214. 

monopthalmica,  215. 

Dorsal  region,  injury  of,  57,  262. 

ELECTRICITY,  289. 
Electric   irritability,    loss   of 
58,  155- 
Electric  tests,  62,  152, 
Embolism,  200. 
Epilepsy,  189. 


297 


298 


INDEX. 


Evidence,  medical,  272. 
Extravasation  into  spinal  cord,  73. 

meningeal,  95. 

Eyeball,  concussion  of,  206. 
Eyes,  affections  of,  147,  206,  217. 

FATAL  lesions,  71. 
Fmgers.  contraction  of,  100. 

crush  of,  203.    « 

Fractures  of  spine,  55,  56,  75. 
union  of,  205. 

GAIT  in  spinal  injury,  150,  168. 
Genito-urinary  organs,  affec- 
tions of,  155. 

HEMATURIA.  196,  200. 
Haemorrhage,         intestinal, 
196. 
— -  into  spinal  canal,  71, 
Hammond,  on  paraplegia,  73. 
Hearing,  impairment  of,  147. 
Hemicrania,  99. 
Hemiplegia,  57,  127,  167. 
Hernia  of  cord,  72. 
Hiccough,  194, 

Hyperassthesia,  61,  62,  63,  98,  149. 
Hypermetropia,  217. 
Hysteria,  174,  259. 

IMPOSITION,  cases  of,  251, 
1      Induration  of  cord,  164. 
Inflammation  of  cord,  27,  70,  158. 

of    membranes,    28,     70,   73, 

158. 


— ;—  of  optic  nerve,  217,  218,  227. 
Injuries  of  head    and    spine  con- 
trasted, 76. 
Intellect,  impairment  of,  146, 
Intestinal  complications,  194, 

JACCOMB  on  electric  tests,  61. 
Jar  in  railway   accidents,   91, 
114. 
Jones  Wharton  on  failure  of  sight, 

218,  223. 
on  the  sympathetic,  223,  225, 

LACERATION   of  membranes, 
71,  72. 

of  ligamentainterspinalia,  76. 

of  intervertebralia,  50. 

— —  of  subflava,   75. 

Limbs,  condition  of,  154,  167. 


Lordat,  Count  de,  case  of,  22. 
Lumbar  region,  injury  of,  57,  262. 


M 


ATY,  Dr. ,  on  palsy  after  fall, 


22. 


Mayes,    Dr.,     on    suppuration    of 

membranes,  75. 
Mayo,  Dr. ,  on  concussion  of  spine, 

28. 
Medical  evidence,  272. 
Medico-legal  aspects  of  concussion, 

240,  26  i. 
Membranes,   inflammation  of,  27, 

70,  73,  81,  158, 

laceration  of,  70,  71. 

suppuration  of,  73,  74. 

Memory,    impairment   of,    32,  46, 

86,  103,  145. 
Meningitis,  cerebral,  28,  70,  166. 

cerebrospinal,  89,  166. 

spinal,  28,  70,  74,  81. 

Meningo  myelitis,  159,  162,  164. 

diagnosis  of,  255. 

morbid  anatomy  of,  162. 

Mental  condition,  145,  179. 
Mercur)'  in  spinal  injury,  287. 
Molecular  changes  in  cord,  158. 
Motion,  loss  of,  57,  103. 
Movement    of     limbs    in     recum- 
bency, 152. 

of  spine,  149, 

Muller  on  intraspinal  haemorrhage, 

72. 
Muscles,  changes  in,  155. 

contraction  of,  87,  155,  167. 

electric  irritability,  155. 

rigidity   of,    19,    29,  61,  155, 

166. 
Myelitis,   27,    70. 
Myopia,  216. 


complications,      189, 
of,      anterior 


Nerves,      affection 

crural,     58. 

auditory,  148. 

circumflex,  43,  55,  112,  250. 

fifth  pair,  190. 

interosseous  posterior,  236. 

musculo-spiral,    43,    55,   ill, 

153-  231. 

obturator,  59. 

peripheral,  201. 

— —  popliteal  external,  60. 


INDEX. 


299 


Nerves,    affections     of,    popliteal 
internal,  59. 

seventh  pair,  189 

spinal  accessory,  112,  189. 

subscapsular,  230. 

ulnar,  154. 

Neuralgia,  62,  99, 
Noises  in  the  head,  146. 
Numbness,  154. 

OCCURRENCE  of  concussion, 
mode  of,  141. 
Ollivier  on   spinal  injury,    29,  70, 

74. 
Ophthalmoscopic  changes,   211. 
Opinion,  discrepancy  of,  79,  272. 
Optic  nervous  apparatus,  224. 
Optic  nerve,  atrophy  of,  208. 
nerve,    inflamation    of.    217, 

218,  228. 
Order  of  symptoms,  155. 

PAIN,  62,  70,  149,  166. 
Paralysis  after  twists,  127. 

complete,  44. 

motor,  37,  51,  57,  151. 

sensory,  33,  36,  51,  62,  152. 

spinal  anaemia,  172. 

■ varieties  of,  57. 

Paralysis  and  weakness  contrasted, 

255. 
Paraplegia,  29. 

after  twists,  128,  130. 

amputation  in,  37. 

Paresis,  169, 

Pathology  of  concussion,  157. 
Period  of  onset,  144,  156. 
Peronation,  impairment  of,  40. 
Peronei  muscles,  paralysis  of,  58. 
Phlebitis,  93,  130,  200. 
Photophobia,  147. 
Pleuro-pneumonia,  93, 
Plexus,  brachial,  injury  of,  39. 

lumbo-sacral,  59. 

Position,  influence  of,  114. 

in  paraplegia,  152. 

Pregnancy,  201. 
Priapism,  68;  155. 
Prognosis  of  concussion,  261. 

as  to  life,  262. 

as  to  recovery,  265. 

elements  of,  80, 

Psoas  muscles,  paralysis  of,  58. 
Ptosis,  190. 


Pulse,  Ftate  of,  156,  180,  182. 
Pupils,  Slate  of,  147. 


RAILWAY  injuries,  mechanism 
of,  114. 

nature  of,  80. 

Railway  spine,  21. 
Recovery,  complete,  266. 

partial,  267. 

Retina,  hyperaemia  of,  217,  218. 
Rlieumatism,  257. 
Rigidity   of   muscles;    19    29,   61. 
155,  166. 

SACRODYNIA,  185. 
Sensation,     increased,       149, 

153. 

paralysis  of,  62.  151,  153. 

perverted,  65,  153, 

subiective,  151,  154,  167. 

Senses,  special,  affection  of.  146, 
Sexual  power,  impairment  of,  102 

156. 
Shock,  general,  93,  173. 

moral,  174. 

Sight,  impairment  of,  34,  48,  147, 
Sleep,  protective  influence  of,  113 

in  spinal  concussion,  146. 

therapeutics  of,  286. 

Smell,  loss  of,  148. 

perverted,  104,  148. 

Spasm  of  muscles,  19,  57,  61,  70, 
Speech,  affection  of,  148. 
Sphincters,   paralysis  of,    67,   153, 

155- 
Spinal  aneemia,  159,  168,  zjo. 

diagnosis  of,  255. 

Spinal  anaemia,  treatment  of,  290. 
Spinal  cord,  extravasation  into,  72. 

hernia  of,  73. 

inflammation  of,  27,  70,  162. 

softening  of,  73,  77,  164. 

Spinal  irritability,  170. 
Spine,  concussion  of,  27. 

dislocation  of,  52. 

examination  of,  149. 

fracture  of,  56. 

injury  of,  26. 

rigidity  of,  107. 

severe  direct  injury  of,  26, 

sprains  of,  115,  T17, 

twists  of,  115,  117, 

Sprains  of  spine,  cause  of,  117. 
complications  of,  119,  121. 


300 


INDEX. 


Sprains  of  spine,  effects  of,  121, 
«- —  prognosis  of,  iig. 
Stammering,  112,  148. 
Strabismus,  147,  190. 
Struma,  effects  of,  119. 
Suppuration  of  membranes,  73,  75. 
Sympathetic  nerve,  distribution  of, 
225. 

influence  of,  225. 

injury  of,  223. 

irritation  of.  227. 

section  of,  227. 

Symptoms,  cerebral,  165. 

feigned,  253. 

nature  of,  113,  249. 

onset  of,  143,  156. 

order  of,  156. 

secondary,  145. 

spinal,  149. 

Syphilis,  190. 

TA.STE,  impairment  of,  148. 
Teale,   J.  W.,  on  high   tem- 
perature, 69. 
Temperature,    depression    of,     69, 

154. 

elevation  of,  69. 

Termination  of  concussion,  70. 

Tetanic  spasms  after  crush  of  fin- 
ger, 203. 

Thrombosis,  200. 

Touch,  sense  of,  148. 


Transmission  of  effects  of  injury 

18. 
Treatment  of  concussion,  281 
Typhoid  fever,  260. 
Twists  of  spine,  115. 

T  TNCONSCIOUSNESS,  183. 
U      Urinary     organs,     complica- 
tions of,  199. 
Urine,  acidity  of,  in  paraplegia,  31, 

33,  155. 

alkalinity  of,  67,  155,  161. 

incontinence  of,  67,  155. 

letentionof,  67,  155,  199. 

VISION,    impairment    of,    147 
206. 

after  blows  on  the  face,  207. 

from  injury  to  fifth  pair,  209. 

to  spine,  214. 

to  sympathetic,  223. 

Vomiting,    192. 

IT  WEAKNESS  after  strains,  118, 

Weakness  and  paralvsis  contrasted, 

255. 
Weight  of  body,  155. 
Wounds,  repair  of,  205. 
Wrenches  of  soine.  117. 

'VONE,  hyperaesthesic,  62. 


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